Provider Demographics
NPI:1548312655
Name:LONG, MARIE (MSPT)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12540 SW 68TH AVE
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8597
Mailing Address - Country:US
Mailing Address - Phone:503-974-9078
Mailing Address - Fax:503-974-9083
Practice Address - Street 1:17120 PILKINGTON RD
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-5353
Practice Address - Country:US
Practice Address - Phone:503-974-9078
Practice Address - Fax:503-974-9083
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4429225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic