Healthcare Provider Details

I. General information

NPI: 1013831585
Provider Name (Legal Business Name): KURUSTUN SHANELLE LONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2026
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 LEE ST
BRISTOL VA
24201-4344
US

IV. Provider business mailing address

20910 US HIGHWAY 58
CASTLEWOOD VA
24224-6103
US

V. Phone/Fax

Practice location:
  • Phone: 276-821-5600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number14415170
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: