1144747213 NPI number — GARY W LONG JR. LCSW-C

Table of content: GARY W LONG JR. LCSW-C (NPI 1144747213)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144747213 NPI number — GARY W LONG JR. LCSW-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LONG
Provider First Name:
GARY
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
LCSW-C
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:
1144747213
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
922 NATIONAL HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAVALE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21502-7325
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
240-362-7294
Provider Business Mailing Address Fax Number:
240-362-7357

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
922 NATIONAL HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAVALE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21502-7325
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
240-362-7294
Provider Business Practice Location Address Fax Number:
240-362-7357
Provider Enumeration Date:
08/29/2017

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:  20551 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 20551 . This is a "BOARD OF SOCIAL WORK-LICENSE VERIFICATION INFORMATION" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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