Provider Demographics
NPI:1033440300
Name:LONG, BOBBY H
Entity Type:Individual
Prefix:
First Name:BOBBY
Middle Name:H
Last Name:LONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6003 N ROBINSON AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73118-7425
Mailing Address - Country:US
Mailing Address - Phone:405-831-3202
Mailing Address - Fax:
Practice Address - Street 1:105 SE 45TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73129-3201
Practice Address - Country:US
Practice Address - Phone:405-632-1900
Practice Address - Fax:405-632-1976
Is Sole Proprietor?:No
Enumeration Date:2010-01-26
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
OK4812101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional