Provider Demographics
NPI:1366709214
Name:LONG, HEATHER D (PTA)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:D
Last Name:LONG
Suffix:
Gender:F
Credentials:PTA
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Mailing Address - Street 1:10015 OLD COLUMBIA RD
Mailing Address - Street 2:SUITE B-215
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21046-1703
Mailing Address - Country:US
Mailing Address - Phone:410-356-6161
Mailing Address - Fax:410-510-1779
Practice Address - Street 1:1361 BRASS MILL RD STE B
Practice Address - Street 2:
Practice Address - City:BELCAMP
Practice Address - State:MD
Practice Address - Zip Code:21017-1213
Practice Address - Country:US
Practice Address - Phone:410-273-2060
Practice Address - Fax:410-273-2404
Is Sole Proprietor?:No
Enumeration Date:2012-04-17
Last Update Date:2012-04-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MDA3522225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant