1528157443 NPI number — JO MARY LONG LICSW

Table of content: JO MARY LONG LICSW (NPI 1528157443)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528157443 NPI number — JO MARY LONG LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LONG
Provider First Name:
JO MARY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528157443
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/02/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
519 AMERICAN LEGION HWY
Provider Second Line Business Mailing Address:
STE 2
Provider Business Mailing Address City Name:
WESTPORT
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02790-4100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-636-6423
Provider Business Mailing Address Fax Number:
508-636-8041

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
519 AMERICAN LEGION HWY
Provider Second Line Business Practice Location Address:
STE 2
Provider Business Practice Location Address City Name:
WESTPORT
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02790-4100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-636-6423
Provider Business Practice Location Address Fax Number:
508-636-8041
Provider Enumeration Date:
10/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  1021707 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 1021707 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 406654 . This is a "BLUE CHIP" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 21079-7 . This is a "BLUE CROSS/BLUE SHIELD RI" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 6207031 . This is a "UNITED BEHAVIORAL HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: P06403 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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