Provider Demographics
NPI:1083075428
Name:LONG, SHELLY ANN (LLBSW)
Entity Type:Individual
Prefix:MRS
First Name:SHELLY
Middle Name:ANN
Last Name:LONG
Suffix:
Gender:F
Credentials:LLBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2012 BONE RD
Mailing Address - Street 2:
Mailing Address - City:HOLLY
Mailing Address - State:MI
Mailing Address - Zip Code:48442-9106
Mailing Address - Country:US
Mailing Address - Phone:248-417-1196
Mailing Address - Fax:
Practice Address - Street 1:420 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-2445
Practice Address - Country:US
Practice Address - Phone:181-025-7370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-13
Last Update Date:2016-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802088852104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker