Provider Demographics
NPI:1114979986
Name:LONG, TIMOTHY RICHARD (LICSW)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:RICHARD
Last Name:LONG
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 DRAPER AVE
Mailing Address - Street 2:C/O CHILD INC.
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02889-5047
Mailing Address - Country:US
Mailing Address - Phone:401-732-5200
Mailing Address - Fax:
Practice Address - Street 1:160 DRAPER AVE
Practice Address - Street 2:C/O CHILD INC.
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02889-5047
Practice Address - Country:US
Practice Address - Phone:401-732-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW013941041C0700X
MA10245841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI29583OtherBLUE CROSS COMMERCIAL
RITL43466Medicaid
RI412638OtherBLUE CROSS BLUE CHIP