Provider Demographics
NPI:1417450776
Name:LONG, CARLENE
Entity Type:Individual
Prefix:
First Name:CARLENE
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7544 W STACY DR
Mailing Address - Street 2:
Mailing Address - City:VENTRESS
Mailing Address - State:LA
Mailing Address - Zip Code:70783-3915
Mailing Address - Country:US
Mailing Address - Phone:225-240-0928
Mailing Address - Fax:
Practice Address - Street 1:7544 W STACY DR
Practice Address - Street 2:
Practice Address - City:VENTRESS
Practice Address - State:LA
Practice Address - Zip Code:70783-3915
Practice Address - Country:US
Practice Address - Phone:225-240-0928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-13
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA0000000Medicaid