Provider Demographics
NPI:1073861779
Name:LONG, KELLIE NICOLE (BSW)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:NICOLE
Last Name:LONG
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3255 WING ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-4638
Mailing Address - Country:US
Mailing Address - Phone:619-221-8600
Mailing Address - Fax:619-221-8619
Practice Address - Street 1:3255 WING ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-4638
Practice Address - Country:US
Practice Address - Phone:619-221-8600
Practice Address - Fax:619-221-8619
Is Sole Proprietor?:No
Enumeration Date:2012-08-28
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program