Provider Demographics
NPI:1326654161
Name:LONG, MICHELLE DIANE (LCPAT)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:DIANE
Last Name:LONG
Suffix:
Gender:F
Credentials:LCPAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8580 E BELLEWOOD PL
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80237-2906
Mailing Address - Country:US
Mailing Address - Phone:469-834-6075
Mailing Address - Fax:
Practice Address - Street 1:10630 LITTLE PATUXENT PKWY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-3264
Practice Address - Country:US
Practice Address - Phone:410-740-8066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-17
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDATC340101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional