MEDICARE: MARIE LONG MSPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	4429	OR
2	2251X0800X	Orthopedic Physical Therapist	4429	OR

General Provider Information

NPI Number	:	1548312655
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIE LONG MSPT

Provider Business Mailing Address
First Line	:	12540 SW 68TH AVE
Second Line	:
City	:	TIGARD
State	:	OR
Zip	:	97223-8597
Country	:	US
Telephone Number	:	503-974-9078
Fax Number	:	503-974-9083

Provider Business Practice Location Address
First Line	:	17120 PILKINGTON RD
Second Line	:
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97035-5353
Country	:	US
Telephone Number	:	503-974-9078
Fax Number	:	503-974-9083

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/17/2007
Last Update Date	:	12/11/2023

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Directions to “ MARIE LONG MSPT” Practice Location

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