Provider Demographics
NPI:1073896635
Name:LONG, ANNEMIEKE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ANNEMIEKE
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ANNEMIEKE
Other - Middle Name:INGHAM
Other - Last Name:STEVENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:171 LAWRENCE ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-2221
Mailing Address - Country:US
Mailing Address - Phone:541-968-1244
Mailing Address - Fax:
Practice Address - Street 1:171 LAWRENCE ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2221
Practice Address - Country:US
Practice Address - Phone:541-968-1244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-21
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL6861101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health