Provider Demographics
NPI:1063594406
Name:LONG, DEBRA S (RT(R)(T))
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:S
Last Name:LONG
Suffix:
Gender:F
Credentials:RT(R)(T)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8920 PRAIRIE TRL
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-9084
Mailing Address - Country:US
Mailing Address - Phone:317-988-3011
Mailing Address - Fax:
Practice Address - Street 1:1481 W 10TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2803
Practice Address - Country:US
Practice Address - Phone:317-988-3011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1715092471R0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471R0002XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiation Therapy