Healthcare Provider Details

I. General information

NPI: 1548170731
Provider Name (Legal Business Name): AMANDA GRACE LONG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2026
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 MANOR DR
CASPER WY
82609-3177
US

IV. Provider business mailing address

1340 MANOR DR
CASPER WY
82609-3177
US

V. Phone/Fax

Practice location:
  • Phone: 307-277-4262
  • Fax:
Mailing address:
  • Phone: 307-277-4262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: