Provider Demographics
NPI:1447816830
Name:LONG, KELSEY
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 ATLANTIC ST
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06901-3523
Mailing Address - Country:US
Mailing Address - Phone:909-653-3798
Mailing Address - Fax:
Practice Address - Street 1:355 ATLANTIC ST
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06901-3523
Practice Address - Country:US
Practice Address - Phone:909-653-3798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-12
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6462235Z00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program