Provider Demographics
NPI:1336701127
Name:LONG, RAYMOND B (BA)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:B
Last Name:LONG
Suffix:
Gender:M
Credentials:BA
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 7072
Mailing Address - Street 2:
Mailing Address - City:WINSLOW
Mailing Address - State:AZ
Mailing Address - Zip Code:86047-7072
Mailing Address - Country:US
Mailing Address - Phone:928-657-8000
Mailing Address - Fax:
Practice Address - Street 1:NORTHEAST OF BASHAS'
Practice Address - Street 2:
Practice Address - City:DILKON
Practice Address - State:AZ
Practice Address - Zip Code:86047
Practice Address - Country:US
Practice Address - Phone:928-657-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-02
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral