Provider Demographics
NPI:1033721816
Name:LONG, KACY
Entity Type:Individual
Prefix:
First Name:KACY
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 1:406 VIRGIL AVE
Mailing Address - Street 2:
Mailing Address - City:SEARCY
Mailing Address - State:AR
Mailing Address - Zip Code:72143-3719
Mailing Address - Country:US
Mailing Address - Phone:850-691-9496
Mailing Address - Fax:
Practice Address - Street 1:120 W RACE AVE STE 10
Practice Address - Street 2:
Practice Address - City:SEARCY
Practice Address - State:AR
Practice Address - Zip Code:72143-4237
Practice Address - Country:US
Practice Address - Phone:850-691-9496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-21
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA1907085101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health