MEDICARE: LAURIE 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	231H00000X	Audiologist	1601000160	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1601000160	OTHER	MI	LICENSE

General Provider Information

NPI Number	:	1902077431
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURIE LONG

Provider Business Mailing Address
First Line	:	3500 W MAPLE RD
Second Line	:	STE. C
City	:	BLOOMFIELD HILLS
State	:	MI
Zip	:	48301-3308
Country	:	US
Telephone Number	:	248-203-9760
Fax Number	:	248-203-6690

Provider Business Practice Location Address
First Line	:	3500 W MAPLE RD
Second Line	:	STE. C
City	:	BLOOMFIELD HILLS
State	:	MI
Zip	:	48301-3308
Country	:	US
Telephone Number	:	248-203-9760
Fax Number	:	248-203-6690

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

Provider Enumeration Date	:	03/12/2008
Last Update Date	:	01/10/2012

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Directions to “ LAURIE LONG ” Practice Location

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