Provider Demographics
NPI:1093330912
Name:LONG, MATTHEW W (LCSW)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:W
Last Name:LONG
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 W OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80521-2716
Mailing Address - Country:US
Mailing Address - Phone:970-310-3406
Mailing Address - Fax:
Practice Address - Street 1:832 W EISENHOWER BLVD STE B5
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80537-3134
Practice Address - Country:US
Practice Address - Phone:970-430-6751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-16
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCSW.099267151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical