Provider Demographics
NPI:1417628686
Name:LONGLEY, STEPHEN R (LCSW)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:R
Last Name:LONGLEY
Suffix:
Gender:M
Credentials:LCSW
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 588
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-0588
Mailing Address - Country:US
Mailing Address - Phone:802-442-5491
Mailing Address - Fax:802-442-3363
Practice Address - Street 1:100 LEDGEHILL RD
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-5200
Practice Address - Country:US
Practice Address - Phone:802-442-5491
Practice Address - Fax:802-442-3363
Is Sole Proprietor?:No
Enumeration Date:2021-09-27
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL066961001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT6139Other030199213