Provider Demographics
NPI:1053769083
Name:LONG, MELISSA (PT, DPT)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 HEADWATERS DR
Mailing Address - Street 2:
Mailing Address - City:HARWICH
Mailing Address - State:MA
Mailing Address - Zip Code:02645-1028
Mailing Address - Country:US
Mailing Address - Phone:508-430-1717
Mailing Address - Fax:
Practice Address - Street 1:111 HEADWATERS DR
Practice Address - Street 2:
Practice Address - City:HARWICH
Practice Address - State:MA
Practice Address - Zip Code:02645-1028
Practice Address - Country:US
Practice Address - Phone:508-430-1717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-31
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20304225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist