Provider Demographics
NPI:1205013695
Name:LONG, LISA JAYNE (MA CCC-S)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:JAYNE
Last Name:LONG
Suffix:
Gender:F
Credentials:MA CCC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:158 NIGHBERT AVE
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601-4003
Mailing Address - Country:US
Mailing Address - Phone:304-752-8962
Mailing Address - Fax:
Practice Address - Street 1:506 HOLLY AVE
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-3306
Practice Address - Country:US
Practice Address - Phone:304-792-2073
Practice Address - Fax:304-752-7471
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-28
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV12089807235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7402318000Medicaid