Provider Demographics
NPI:1174782684
Name:LONG, HEIDI K (DPT)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:K
Last Name:LONG
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:K
Other - Last Name:SPEARS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:746 FAIRMONT ROAD
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26501-4060
Mailing Address - Country:US
Mailing Address - Phone:304-225-5222
Mailing Address - Fax:
Practice Address - Street 1:746 FAIRMONT RD
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26501-4060
Practice Address - Country:US
Practice Address - Phone:304-225-5222
Practice Address - Fax:304-225-5224
Is Sole Proprietor?:No
Enumeration Date:2008-06-09
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV11880792OtherCAQH
WV3810012350Medicaid