1629102124 NPI number — MARY MARGARET LONG LCPC, MAC

Table of content: MARY MARGARET LONG LCPC, MAC (NPI 1629102124)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629102124 NPI number — MARY MARGARET LONG LCPC, MAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LONG
Provider First Name:
MARY
Provider Middle Name:
MARGARET
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCPC, MAC
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:
1629102124
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/20/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
CMR 450 BOX 1213
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
APO
Provider Business Mailing Address State Name:
AE
Provider Business Mailing Address Postal Code:
09705-0013
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
326-536-4377
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
AVENUE D'OSLO BLDG 401
Provider Second Line Business Practice Location Address:
UNIT 21420
Provider Business Practice Location Address City Name:
APO
Provider Business Practice Location Address State Name:
AE
Provider Business Practice Location Address Postal Code:
09705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-566-5320
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/15/2007

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: 101YA0400X , with the licence number:  501904 ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: LCPC-3666 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 002269500 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000010146797 . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: Q7358 . This is a "BLUE CROSS OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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