Provider Demographics
NPI:1114258878
Name:LONG, BRET A
Entity Type:Individual
Prefix:
First Name:BRET
Middle Name:A
Last Name:LONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2204 PACIFIC AVENUE N
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:WA
Mailing Address - Zip Code:98631
Mailing Address - Country:US
Mailing Address - Phone:360-642-3787
Mailing Address - Fax:360-642-2096
Practice Address - Street 1:2204 PACIFIC AVENUE N
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:WA
Practice Address - Zip Code:98631
Practice Address - Country:US
Practice Address - Phone:360-642-3787
Practice Address - Fax:360-642-2096
Is Sole Proprietor?:No
Enumeration Date:2010-01-20
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00045309101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor