Provider Demographics
NPI:1356684005
Name:LONG, CHRISTINE DIANNE
Entity Type:Individual
Prefix:MRS
First Name:CHRISTINE
Middle Name:DIANNE
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHRISTIE
Other - Middle Name:DIANNE
Other - Last Name:BEAUCHAMP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1904 RICHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CERES
Mailing Address - State:CA
Mailing Address - Zip Code:95307-4562
Mailing Address - Country:US
Mailing Address - Phone:209-541-2121
Mailing Address - Fax:
Practice Address - Street 1:1904 RICHLAND AVE
Practice Address - Street 2:
Practice Address - City:CERES
Practice Address - State:CA
Practice Address - Zip Code:95307-4562
Practice Address - Country:US
Practice Address - Phone:209-541-2121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-01
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility