=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497215743
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHERITA LONG
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2019
-----------------------------------------------------
Last Update Date | 06/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8555 CEDAR PLACE DR STE 112
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46240-2344
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-750-5189
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 7072
-----------------------------------------------------
City | FISHERS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46038-7072
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-656-7090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 373H00000X
-----------------------------------------------------
Taxonomy Name | Day Training/Habilitation Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------