Provider Demographics
NPI:1053611863
Name:LONG, MICHELLE D (MA60177937)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:D
Last Name:LONG
Suffix:
Gender:F
Credentials:MA60177937
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 N 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-2632
Mailing Address - Country:US
Mailing Address - Phone:509-965-5750
Mailing Address - Fax:
Practice Address - Street 1:361 LAMPE RD
Practice Address - Street 2:
Practice Address - City:SELAH
Practice Address - State:WA
Practice Address - Zip Code:98942-9534
Practice Address - Country:US
Practice Address - Phone:509-440-1534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-26
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60177937225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist