Provider Demographics
NPI:1174538581
Name:DE LONG, C FREDERICK (PHD)
Entity type:Individual
Prefix:
First Name:C
Middle Name:FREDERICK
Last Name:DE LONG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:FRED
Other - Middle Name:
Other - Last Name:DE LONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:14 FOREST RD
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:PA
Mailing Address - Zip Code:19087-3204
Mailing Address - Country:US
Mailing Address - Phone:610-688-0418
Mailing Address - Fax:
Practice Address - Street 1:14 FOREST RD
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:PA
Practice Address - Zip Code:19087-3204
Practice Address - Country:US
Practice Address - Phone:610-688-0418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS006601L103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling