Provider Demographics
NPI:1619407939
Name:LONG, JOSEPH MAXWELL (ATC, LAT, SCAT, BS)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:MAXWELL
Last Name:LONG
Suffix:
Gender:M
Credentials:ATC, LAT, SCAT, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:117 RUSSELL RD APT 201
Mailing Address - Street 2:
Mailing Address - City:CAYCE
Mailing Address - State:SC
Mailing Address - Zip Code:29033-1983
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:117 RUSSELL RD APT 201
Practice Address - Street 2:
Practice Address - City:CAYCE
Practice Address - State:SC
Practice Address - Zip Code:29033-1983
Practice Address - Country:US
Practice Address - Phone:803-487-3510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-19
Last Update Date:2017-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLAT-31162255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer