Provider Demographics
NPI:1275727810
Name:LONG, JANE KHIET T (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JANE KHIET
Middle Name:T
Last Name:LONG
Suffix:
Gender:F
Credentials:LCSW
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Mailing Address - Street 1:227 MADISON ST
Mailing Address - Street 2:GOUVERNEUR HEALTHCARE SERVICES, BEHAVIORAL HEALTH DEPT.
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10002-7537
Mailing Address - Country:US
Mailing Address - Phone:212-238-7614
Mailing Address - Fax:212-238-7009
Practice Address - Street 1:227 MADISON ST
Practice Address - Street 2:GOUVERNEUR HEALTHCARE SERVICES, BEHAVIORAL HEALTH DEPT.
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-7537
Practice Address - Country:US
Practice Address - Phone:212-238-7614
Practice Address - Fax:212-238-7009
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-28
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY0782511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY078251OtherNYS SOCIAL WORK LICENSE NUMBER