Provider Demographics
NPI:1205223724
Name:LONG, EVALY (LM, CPM)
Entity Type:Individual
Prefix:
First Name:EVALY
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:LM, CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 SAN ANTONIO AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-3910
Mailing Address - Country:US
Mailing Address - Phone:415-728-8893
Mailing Address - Fax:
Practice Address - Street 1:1310 SAN ANTONIO AVE
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-3910
Practice Address - Country:US
Practice Address - Phone:415-728-8893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-22
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA426176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife