Provider Demographics
NPI:1073386009
Name:LONG, RACHEL M
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:M
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 1:79 GLENRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GLENVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12302-4528
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:526 OLD LIVERPOOL RD STE 4
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-6249
Practice Address - Country:US
Practice Address - Phone:315-453-3911
Practice Address - Fax:315-453-0197
Is Sole Proprietor?:No
Enumeration Date:2023-11-01
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY72-P125406-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker