Provider Demographics
NPI:1417681339
Name:LONG, VONDA (CERT PSYCHOLOGY)
Entity Type:Individual
Prefix:MS
First Name:VONDA
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:CERT PSYCHOLOGY
Other - Prefix:MS
Other - First Name:VONDA
Other - Middle Name:
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CERT PSYCHOLOGY
Mailing Address - Street 1:1200 MARLTON PIKE E
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08034-2122
Mailing Address - Country:US
Mailing Address - Phone:609-310-8756
Mailing Address - Fax:
Practice Address - Street 1:1200 MARLTON PIKE E
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034-2122
Practice Address - Country:US
Practice Address - Phone:609-310-8756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-15
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJBGXXAVRBE6103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist