Provider Demographics
NPI:1114165412
Name:LONG, PATRICIA JOANN (LCMHC)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:JOANN
Last Name:LONG
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 54
Mailing Address - Street 2:
Mailing Address - City:HYDE PARK
Mailing Address - State:VT
Mailing Address - Zip Code:05655-0054
Mailing Address - Country:US
Mailing Address - Phone:802-793-7687
Mailing Address - Fax:
Practice Address - Street 1:257 MAIN STREET
Practice Address - Street 2:
Practice Address - City:HYDE PARK
Practice Address - State:VT
Practice Address - Zip Code:05655
Practice Address - Country:US
Practice Address - Phone:802-793-7687
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-26
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT068 0000382101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health