Provider Demographics
NPI:1043357809
Name:LONG, LAKITA DENISE (MS)
Entity Type:Individual
Prefix:MS
First Name:LAKITA
Middle Name:DENISE
Last Name:LONG
Suffix:
Gender:F
Credentials:MS
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 3902
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94531-3902
Mailing Address - Country:US
Mailing Address - Phone:925-238-8711
Mailing Address - Fax:
Practice Address - Street 1:915 W 4TH ST
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-1118
Practice Address - Country:US
Practice Address - Phone:925-238-8711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA79723106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist