Provider Demographics
NPI:1164435244
Name:STANLEY LONG DBA HARBOR LIGHTS PROFESSIONAL CHEMICAL DEPENDENCY SERVIC
Entity Type:Organization
Organization Name:STANLEY LONG DBA HARBOR LIGHTS PROFESSIONAL CHEMICAL DEPENDENCY SERVIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:E
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-963-0777
Mailing Address - Street 1:PO BOX 716
Mailing Address - Street 2:3358 MAIN ST
Mailing Address - City:MEXICO
Mailing Address - State:NY
Mailing Address - Zip Code:13114
Mailing Address - Country:US
Mailing Address - Phone:315-963-0777
Mailing Address - Fax:345-963-0611
Practice Address - Street 1:3358 MAIN ST
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:NY
Practice Address - Zip Code:13114
Practice Address - Country:US
Practice Address - Phone:315-963-0777
Practice Address - Fax:345-963-0611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
NY080211024261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01463294Medicaid