Provider Demographics
NPI:1134684228
Name:LONG, LORRIE RENE
Entity Type:Individual
Prefix:
First Name:LORRIE
Middle Name:RENE
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 W 7 MILE RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48203-1967
Mailing Address - Country:US
Mailing Address - Phone:313-893-6172
Mailing Address - Fax:313-893-0064
Practice Address - Street 1:62 W 7 MILE RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48203-1967
Practice Address - Country:US
Practice Address - Phone:313-893-6172
Practice Address - Fax:313-893-0064
Is Sole Proprietor?:No
Enumeration Date:2019-02-04
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011026241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3434247Medicaid