Provider Demographics
NPI:1194372102
Name:LONG, ELIZABETH VICTORIA (LCSW)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:VICTORIA
Last Name:LONG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10100 ELIDA RD
Mailing Address - Street 2:
Mailing Address - City:DELPHOS
Mailing Address - State:OH
Mailing Address - Zip Code:45833-9056
Mailing Address - Country:US
Mailing Address - Phone:419-695-8010
Mailing Address - Fax:419-695-0004
Practice Address - Street 1:100 EXECUTIVE PARK STE 103
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4201
Practice Address - Country:US
Practice Address - Phone:502-313-6880
Practice Address - Fax:502-473-1334
Is Sole Proprietor?:No
Enumeration Date:2019-08-23
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY254350104100000X
KY2571611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY254350OtherBOARD OF SOCIAL WORK