Healthcare Provider Details

I. General information

NPI: 1952686099
Provider Name (Legal Business Name): RACHEL ANN LONG LPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2011
Last Update Date: 10/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 N JEFFERSON ST
ROANOKE VA
24016-1427
US

IV. Provider business mailing address

6640 TREVILIAN RD
ROANOKE VA
24019-5038
US

V. Phone/Fax

Practice location:
  • Phone: 540-345-5111
  • Fax:
Mailing address:
  • Phone: 540-362-0390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306603149
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: