Provider Demographics
NPI:1144733791
Name:LONG, TYLER W (PT, DPT)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:W
Last Name:LONG
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:187 THOMAS JOHNSON DR STE 6
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4382
Mailing Address - Country:US
Mailing Address - Phone:301-473-5945
Mailing Address - Fax:301-473-5901
Practice Address - Street 1:25 LIVELY STREAM WAY BLDG 254
Practice Address - Street 2:
Practice Address - City:GETTYSBURG
Practice Address - State:PA
Practice Address - Zip Code:17325-6021
Practice Address - Country:US
Practice Address - Phone:717-337-4515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-06
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD26771225100000X
PAPT030247225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist