Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225X00000X | Occupational Therapist | ||
N | 225XN1300X | Occupational Therapist - Neurorehabilitation | ||
N | 225XP0019X | Occupational Therapist - Physical Rehabilitation | ||
N | 225XP0200X | Occupational Therapist - Pediatrics | 113413 | TX |
NPI | 1700025475 |
---|---|
Provider Name | Pamela Long |
First Address | Maryville, IL 62062-0203 |
Second Address | Glen Carbon, IL 62034-1561 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/02/2009 |
Last Update Date | 17/03/2018 |