Healthcare Provider Details

I. General information

NPI: 1982048120
Provider Name (Legal Business Name): TALISHA LONG MS CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2013
Last Update Date: 04/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 S DR EE DUNLAP ST
SAN DIEGO TX
78384-2802
US

IV. Provider business mailing address

152 E COUNTY ROAD 2140
KINGSVILLE TX
78363-8909
US

V. Phone/Fax

Practice location:
  • Phone: 361-279-4041
  • Fax:
Mailing address:
  • Phone: 361-522-6056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number102193
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: