Provider Demographics
NPI:1184783151
Name:LONG, LAURA L (RD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:L
Last Name:LONG
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 DEERFIELD WOODS
Mailing Address - Street 2:
Mailing Address - City:LAMBERTVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48144
Mailing Address - Country:US
Mailing Address - Phone:734-854-1356
Mailing Address - Fax:
Practice Address - Street 1:8765 LEWIS AVENUE
Practice Address - Street 2:
Practice Address - City:TEMPERANCE
Practice Address - State:MI
Practice Address - Zip Code:48182
Practice Address - Country:US
Practice Address - Phone:734-847-3802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRD86649133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI772703126Medicaid
MIE86031014Medicare PIN