Provider Demographics
NPI:1548869779
Name:LONG, MARY SUSAN (PT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:SUSAN
Last Name:LONG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:SUSAN
Other - Last Name:GROSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:223 NEVADA LN
Mailing Address - Street 2:
Mailing Address - City:LIGONIER
Mailing Address - State:PA
Mailing Address - Zip Code:15658-2173
Mailing Address - Country:US
Mailing Address - Phone:724-972-3979
Mailing Address - Fax:
Practice Address - Street 1:3960 STATE ROUTE 30
Practice Address - Street 2:
Practice Address - City:LATROBE
Practice Address - State:PA
Practice Address - Zip Code:15650-5518
Practice Address - Country:US
Practice Address - Phone:724-532-3422
Practice Address - Fax:724-532-3424
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-19
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT006507L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist