Provider Demographics
NPI:1164644126
Name:LONGO, JAMES (LPC)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:LONGO
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:365 MONTAUK AVENUE
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320
Mailing Address - Country:US
Mailing Address - Phone:860-442-0711
Mailing Address - Fax:860-444-4767
Practice Address - Street 1:365 MONTAUK AVENUE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320
Practice Address - Country:US
Practice Address - Phone:860-442-0711
Practice Address - Fax:860-444-4767
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000098101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4024972Medicaid
CT4014679Medicaid
CT4024972Medicaid