Provider Demographics
NPI:1356836597
Name:LONG, BENJAMIN RICHARD
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:RICHARD
Last Name:LONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 S RIVER RD STE 2
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:NH
Mailing Address - Zip Code:03110-6930
Mailing Address - Country:US
Mailing Address - Phone:603-255-5267
Mailing Address - Fax:
Practice Address - Street 1:173 S RIVER RD STE 2
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:NH
Practice Address - Zip Code:03110-6930
Practice Address - Country:US
Practice Address - Phone:603-255-5267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-29
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1861106H00000X
MA172V00000X
NH293106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No172V00000XOther Service ProvidersCommunity Health Worker