Provider Demographics
NPI:1346782836
Name:LONG, GINGER
Entity Type:Individual
Prefix:
First Name:GINGER
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38271 MOUND RD
Mailing Address - Street 2:BLDG B SUITE 300
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-3401
Mailing Address - Country:US
Mailing Address - Phone:586-477-2054
Mailing Address - Fax:517-676-5460
Practice Address - Street 1:38271 MOUND RD
Practice Address - Street 2:BLDG B SUITE 300
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-3401
Practice Address - Country:US
Practice Address - Phone:586-477-2054
Practice Address - Fax:517-676-5460
Is Sole Proprietor?:No
Enumeration Date:2016-11-15
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801069792171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator