Individual
MRS. LISA JAYNE LONG
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MA CCC-S
Contact information
Practice address
506 HOLLY AVE, LOGAN, WV 25601-3306
(304) 792-2073
(304) 752-7471
Mailing address
158 NIGHBERT AVE, LOGAN, WV 25601-4003
(304) 752-8962
Taxonomy
Speciality
Code
Description
License number
State
235Z00000X
Speech-Language Pathologist
Primary
12089807
WV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
7402318000
—
WV
Enumeration date
01/28/2008
Last updated
01/28/2008
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