Provider Demographics
NPI:1760231336
Name:LONGENDELPHER, ELIZABETH (OT)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:LONGENDELPHER
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 932184
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-2184
Mailing Address - Country:US
Mailing Address - Phone:856-678-3484
Mailing Address - Fax:
Practice Address - Street 1:150 FOUNTAINS WAY
Practice Address - Street 2:BLDG 4, SUITE 2
Practice Address - City:ST JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259
Practice Address - Country:US
Practice Address - Phone:904-825-2660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-16
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT25158225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist