1104869973 NPI number — JOHN M LONGO LICSW

Table of content: JOHN M LONGO LICSW (NPI 1104869973)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104869973 NPI number — JOHN M LONGO LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LONGO
Provider First Name:
JOHN
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LICSW
Provider Gender Code:
M

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:
1104869973
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/14/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
110 HAVERHILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AMESBURY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01913-2123
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-388-8054
Provider Business Mailing Address Fax Number:
978-388-8033

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 HAVERHILL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AMESBURY
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01913-2123
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-388-8054
Provider Business Practice Location Address Fax Number:
978-388-8033
Provider Enumeration Date:
06/13/2006

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: 1041C0700X , with the licence number:  1132 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 23841 , 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: 1132 . This is a "LICSW" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: P03128 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 23841 . This is a "LICSW" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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