Provider Demographics
NPI:1114689031
Name:LONG, SHELLY D (LMSW)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:D
Last Name:LONG
Suffix:
Gender:F
Credentials:LMSW
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 679
Mailing Address - Street 2:
Mailing Address - City:MORRILTON
Mailing Address - State:AR
Mailing Address - Zip Code:72110-0679
Mailing Address - Country:US
Mailing Address - Phone:501-354-4589
Mailing Address - Fax:501-354-5410
Practice Address - Street 1:1200 W WALNUT ST STE B1100
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-3562
Practice Address - Country:US
Practice Address - Phone:479-278-7028
Practice Address - Fax:479-278-2092
Is Sole Proprietor?:No
Enumeration Date:2021-10-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AR10293-M104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR10293-MOtherSOCIAL WORK LICENSE