Provider Demographics
NPI:1174973457
Name:LONG, LYNNE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:LYNNE
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:LYNNE
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CC-SLP
Mailing Address - Street 1:285 BLACKSTOCK RD
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-4713
Mailing Address - Country:US
Mailing Address - Phone:770-855-1388
Mailing Address - Fax:
Practice Address - Street 1:285 BLACKSTOCK RD
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-4713
Practice Address - Country:US
Practice Address - Phone:770-855-1388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-16
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP001272235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist