Provider Demographics
NPI:1063836690
Name:LONG, JOHN JR
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:LONG
Suffix:JR
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 1:3896 SWENSON ST
Mailing Address - Street 2:APT 1204B
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-7408
Mailing Address - Country:US
Mailing Address - Phone:267-251-3899
Mailing Address - Fax:
Practice Address - Street 1:3896 SWENSON ST
Practice Address - Street 2:APT 1204B
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-7408
Practice Address - Country:US
Practice Address - Phone:267-251-3899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-18
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst