Provider Demographics
NPI:1326274226
Name:LONGO, MARY BETH (CNS)
Entity Type:Individual
Prefix:
First Name:MARY BETH
Middle Name:
Last Name:LONGO
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12300 MCCRACKEN RD
Mailing Address - Street 2:SUITE 137
Mailing Address - City:GARFIELD HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44125-2914
Mailing Address - Country:US
Mailing Address - Phone:216-587-6727
Mailing Address - Fax:216-587-6726
Practice Address - Street 1:12300 MCCRACKEN RD
Practice Address - Street 2:SUITE 137
Practice Address - City:GARFIELD HTS
Practice Address - State:OH
Practice Address - Zip Code:44125-2914
Practice Address - Country:US
Practice Address - Phone:216-587-6727
Practice Address - Fax:216-587-6726
Is Sole Proprietor?:No
Enumeration Date:2009-06-05
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN 194383364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3018166Medicaid
OH3018166Medicaid