Provider Demographics
NPI:1386833275
Name:LONG, SHELLY (LCSW-R)
Entity Type:Individual
Prefix:MRS
First Name:SHELLY
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 E. 1ST STREET
Mailing Address - Street 2:
Mailing Address - City:CORNING
Mailing Address - State:NY
Mailing Address - Zip Code:14830
Mailing Address - Country:US
Mailing Address - Phone:607-936-1771
Mailing Address - Fax:
Practice Address - Street 1:1019 E WATER ST
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14901-3332
Practice Address - Country:US
Practice Address - Phone:607-733-5696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-17
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00074730104100000X
NY077531-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker