Provider Demographics
NPI:1225508146
Name:LONG, KIM MARIE (LCPC)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:MARIE
Last Name:LONG
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W 9TH ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-4541
Mailing Address - Country:US
Mailing Address - Phone:667-600-3310
Mailing Address - Fax:301-694-8221
Practice Address - Street 1:300 W 9TH ST
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-4541
Practice Address - Country:US
Practice Address - Phone:667-600-3310
Practice Address - Fax:301-694-8221
Is Sole Proprietor?:No
Enumeration Date:2018-12-04
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC0743101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional