Provider Demographics
NPI:1235818741
Name:DELONG, CARLA ANN
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:ANN
Last Name:DELONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CAROLE
Other - Middle Name:LYNNESE
Other - Last Name:BROOKS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MRT FACILITATOR
Mailing Address - Street 1:1213 ORMSBY LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-3862
Mailing Address - Country:US
Mailing Address - Phone:502-417-9505
Mailing Address - Fax:
Practice Address - Street 1:1213 ORMSBY LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-3862
Practice Address - Country:US
Practice Address - Phone:502-417-9505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYBACB494620103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst