Provider Demographics
NPI:1871950113
Name:LONG, BLAINE (ATC)
Entity type:Individual
Prefix:DR
First Name:BLAINE
Middle Name:
Last Name:LONG
Suffix:
Gender:M
Credentials:ATC
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Mailing Address - Street 1:1203 HEALTH PROFESSIONS BUILDING
Mailing Address - Street 2:CENTRAL MICHIGAN UNIVERSITY
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48859-9339
Mailing Address - Country:US
Mailing Address - Phone:989-774-2805
Mailing Address - Fax:989-774-3024
Practice Address - Street 1:1203 HEALTH PROFESSIONS BUILDING
Practice Address - Street 2:CENTRAL MICHIGAN UNIVERSITY
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48859-9339
Practice Address - Country:US
Practice Address - Phone:989-774-2805
Practice Address - Fax:989-774-3024
Is Sole Proprietor?:No
Enumeration Date:2016-01-18
Last Update Date:2016-02-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI26010012082255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer