Provider Demographics
NPI:1114813102
Name:LONG, LISA MICHELE
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MICHELE
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:246 HAMPSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:BRANSON
Mailing Address - State:MO
Mailing Address - Zip Code:65616-3486
Mailing Address - Country:US
Mailing Address - Phone:417-332-5339
Mailing Address - Fax:
Practice Address - Street 1:246 HAMPSHIRE DR
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-3486
Practice Address - Country:US
Practice Address - Phone:417-332-5339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-16
Last Update Date:2025-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ23720225CX0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225CX0006XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation CounselorOrientation and Mobility Training Provider