Provider Demographics
NPI:1639643992
Name:LONG, KRISTEN ANNE (LMT)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:ANNE
Last Name:LONG
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 HOLT RD APT 2
Mailing Address - Street 2:
Mailing Address - City:BUZZARDS BAY
Mailing Address - State:MA
Mailing Address - Zip Code:02532-3468
Mailing Address - Country:US
Mailing Address - Phone:774-368-0863
Mailing Address - Fax:
Practice Address - Street 1:680 FALMOUTH RD STE H
Practice Address - Street 2:
Practice Address - City:MASHPEE
Practice Address - State:MA
Practice Address - Zip Code:02649-3338
Practice Address - Country:US
Practice Address - Phone:774-368-0863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-18
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA12120225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist