Provider Demographics
NPI:1083960744
Name:LONG, LORI BETH (MED)
Entity Type:Individual
Prefix:MS
First Name:LORI
Middle Name:BETH
Last Name:LONG
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6780 EASTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33462-3912
Mailing Address - Country:US
Mailing Address - Phone:561-360-5050
Mailing Address - Fax:
Practice Address - Street 1:300 S DIXIE HWY STE A
Practice Address - Street 2:
Practice Address - City:LANTANA
Practice Address - State:FL
Practice Address - Zip Code:33462-3259
Practice Address - Country:US
Practice Address - Phone:561-360-5050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-31
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH2035101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health