Healthcare Provider Details

I. General information

NPI: 1649521279
Provider Name (Legal Business Name): HELEN LONG CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2012
Last Update Date: 11/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 S HOLLYWOOD ST SHELBY COUNTY SCHOOLS
MEMPHIS TN
38112-4801
US

IV. Provider business mailing address

1437 CENTRAL AVE #316
MEMPHIS TN
38104-4890
US

V. Phone/Fax

Practice location:
  • Phone: 901-416-5600
  • Fax: 901-416-5697
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number8977
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP01205
License Number StateRI
# 3
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number5365
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: