Provider Demographics
NPI:1144772567
Name:LONG, SHELLEY LYNN (PHD)
Entity Type:Individual
Prefix:DR
First Name:SHELLEY
Middle Name:LYNN
Last Name:LONG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:SHELLEY
Other - Middle Name:LYNN
Other - Last Name:PETERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:325 OXFORD CT
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:TX
Mailing Address - Zip Code:76262-5063
Mailing Address - Country:US
Mailing Address - Phone:979-571-5046
Mailing Address - Fax:
Practice Address - Street 1:325 OXFORD CT
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:TX
Practice Address - Zip Code:76262-5063
Practice Address - Country:US
Practice Address - Phone:979-571-5046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-02
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19815101YP2500X
TX36498103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional