Provider Demographics
NPI:1093321499
Name:LONG, LAURA (MS, LMFT-T)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:MS, LMFT-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2961 YARMOUTH GREENWAY DR STE 2
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53711-5809
Mailing Address - Country:US
Mailing Address - Phone:608-515-8494
Mailing Address - Fax:
Practice Address - Street 1:2961 YARMOUTH GREENWAY DR STE 2
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:WI
Practice Address - Zip Code:53711-5809
Practice Address - Country:US
Practice Address - Phone:608-515-8494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI697-228106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist