Provider Demographics
NPI:1235812223
Name:LONG, MARSHELLE NIX
Entity Type:Individual
Prefix:
First Name:MARSHELLE
Middle Name:NIX
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2580 GILBERTS BCH
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-8948
Mailing Address - Country:US
Mailing Address - Phone:816-419-7055
Mailing Address - Fax:
Practice Address - Street 1:4336 NORTH BLVD STE 204
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-3920
Practice Address - Country:US
Practice Address - Phone:225-960-7419
Practice Address - Fax:225-960-7421
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2203784617101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2203784617Medicaid
LA221S00000XMedicaid
LA251S00000XMedicaid