MEDICARE: NICKOLES LONG

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	PT018726	OH

General Provider Information

NPI Number	:	1578352571
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICKOLES LONG

Provider Business Mailing Address
First Line	:	5057 DRIVEMERE RD
Second Line	:
City	:	HILLIARD
State	:	OH
Zip	:	43026-1514
Country	:	US
Telephone Number	:	937-672-6098
Fax Number	:

Provider Business Practice Location Address
First Line	:	800 YARD ST STE 300
Second Line	:
City	:	GRANDVIEW HEIGHTS
State	:	OH
Zip	:	43212-3882
Country	:	US
Telephone Number	:	937-672-6098
Fax Number	:

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

Provider Enumeration Date	:	05/05/2025
Last Update Date	:	05/05/2025

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Directions to “ NICKOLES LONG ” Practice Location

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