Provider Demographics
NPI:1386035814
Name:LONG, JODY (LPA, LCAS, CCS)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:LPA, LCAS, CCS
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 4682
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28406-1682
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:116 ELLIOTT DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28405-8433
Practice Address - Country:US
Practice Address - Phone:910-623-0605
Practice Address - Fax:910-338-0495
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-05
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4690103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical