Healthcare Provider Details

I. General information

NPI: 1760189633
Provider Name (Legal Business Name): ELIZABETH CHARLENE LONG CDT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2023
Last Update Date: 02/13/2023
Certification Date: 02/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5903 E 35TH ST
TULSA OK
74135-5305
US

IV. Provider business mailing address

6333 E SKELLY DR
TULSA OK
74135-6106
US

V. Phone/Fax

Practice location:
  • Phone: 918-798-5487
  • Fax:
Mailing address:
  • Phone: 918-798-5487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: