Provider Demographics
NPI:1174747398
Name:LONG, TISH LEE (OTR)
Entity type:Individual
Prefix:MRS
First Name:TISH
Middle Name:LEE
Last Name:LONG
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:MRS
Other - First Name:TISH
Other - Middle Name:LEE
Other - Last Name:SAMBROOK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1337 S INTERNATIONAL PKWY
Mailing Address - Street 2:STE 1321
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-1402
Mailing Address - Country:US
Mailing Address - Phone:407-833-0802
Mailing Address - Fax:
Practice Address - Street 1:1337 S INTERNATIONAL PKWY
Practice Address - Street 2:STE 1321
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-1402
Practice Address - Country:US
Practice Address - Phone:407-833-0802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT7361225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand