Provider Demographics
NPI:1033539440
Name:LONG, ROBERTA
Entity Type:Individual
Prefix:MRS
First Name:ROBERTA
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 76
Mailing Address - Street 2:
Mailing Address - City:HALLETT
Mailing Address - State:OK
Mailing Address - Zip Code:74034
Mailing Address - Country:US
Mailing Address - Phone:918-845-8921
Mailing Address - Fax:
Practice Address - Street 1:570 EAST 3RD
Practice Address - Street 2:
Practice Address - City:HALLETT
Practice Address - State:OK
Practice Address - Zip Code:74034
Practice Address - Country:US
Practice Address - Phone:918-845-8921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-24
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor