Provider Demographics
NPI:1275668469
Name:LONG, GRACE M (PHD)
Entity Type:Individual
Prefix:DR
First Name:GRACE
Middle Name:M
Last Name:LONG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 773
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-0773
Mailing Address - Country:US
Mailing Address - Phone:907-746-1212
Mailing Address - Fax:907-746-7307
Practice Address - Street 1:642 S ALASKA ST STE 218
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-6378
Practice Address - Country:US
Practice Address - Phone:907-746-1212
Practice Address - Fax:907-746-7307
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK480103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1841415320OtherPSYCHOLOGY RESOURCES PC - GROUP NPI