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General NPI Number Information
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NPI Number | 1790029247
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Entity Type | Individual
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Provider Name | MITCHELL LONG PTA
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Gender | Male
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Dates
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Enumeration Date | 11/22/2012
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Last Update Date | 11/22/2012
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Provider Practice Location Address
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Address Line | 328 W VINE ST
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City | EDGERTON
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State | OH
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Zip | 43517-9600
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Country | US
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Telephone | 419-298-2321
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Fax |
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Provider Business Mailing Address
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Address Line | 21786 SWITZER RD
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City | DEFIANCE
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State | OH
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Zip | 43512-9732
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Country | US
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Telephone | 740-975-4464
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | PTA. 08768
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License Number State | OH
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