Provider Demographics
NPI:1043603004
Name:LONG, LYNN DARLENE (LSW)
Entity Type:Individual
Prefix:DR
First Name:LYNN
Middle Name:DARLENE
Last Name:LONG
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 ROBINSON ST
Mailing Address - Street 2:
Mailing Address - City:FORKSTON TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:18629-5045
Mailing Address - Country:US
Mailing Address - Phone:570-240-3684
Mailing Address - Fax:
Practice Address - Street 1:148 ROBINSON ST
Practice Address - Street 2:
Practice Address - City:FORKSTON TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:18629-5045
Practice Address - Country:US
Practice Address - Phone:570-240-3684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-13
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 103K00000X
PASW128735104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst