Provider Demographics
NPI:1750901252
Name:LONG, EDWARD R (PT)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:R
Last Name:LONG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:453 COMMONWEALTH RD
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-8326
Mailing Address - Country:US
Mailing Address - Phone:843-568-9306
Mailing Address - Fax:
Practice Address - Street 1:1476 LONG GROVE DR STE 1
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-7571
Practice Address - Country:US
Practice Address - Phone:843-216-3534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-24
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2081225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist