Provider Demographics
NPI:1407125511
Name:LONG, STEPHANIE MARIE (PHD, MSCP, ABPP)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:MARIE
Last Name:LONG
Suffix:
Gender:F
Credentials:PHD, MSCP, ABPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3530 N COURTHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE FORGE
Mailing Address - State:VA
Mailing Address - Zip Code:23140-3408
Mailing Address - Country:US
Mailing Address - Phone:804-409-7525
Mailing Address - Fax:804-315-9380
Practice Address - Street 1:3530 N COURTHOUSE RD
Practice Address - Street 2:
Practice Address - City:PROVIDENCE FORGE
Practice Address - State:VA
Practice Address - Zip Code:23140-3408
Practice Address - Country:US
Practice Address - Phone:804-409-7525
Practice Address - Fax:804-315-9380
Is Sole Proprietor?:No
Enumeration Date:2011-12-19
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD04975103TC0700X
LA311244103TP0016X
VA810007571103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)