Provider Demographics
NPI:1407821648
Name:LONG, KATHLEEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:PHD
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 6061
Mailing Address - Street 2:
Mailing Address - City:FALMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04105-6061
Mailing Address - Country:US
Mailing Address - Phone:252-349-0219
Mailing Address - Fax:252-636-5677
Practice Address - Street 1:508 GRAY RD
Practice Address - Street 2:
Practice Address - City:WINDHAM
Practice Address - State:ME
Practice Address - Zip Code:04062-4831
Practice Address - Country:US
Practice Address - Phone:252-349-0219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-21
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS1445103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0319VOtherBLUE CROSS BLUE SHIELD NC
NC0319VOtherBLUE CROSS BLUE SHIELD NC
R57018Medicare UPIN