Provider Demographics
NPI:1417718966
Name:LONG, MARK HARDON
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:HARDON
Last Name:LONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2219 DOUGLAS ST NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20018-2129
Mailing Address - Country:US
Mailing Address - Phone:202-288-3247
Mailing Address - Fax:
Practice Address - Street 1:2918 MINNESOTA AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-1127
Practice Address - Country:US
Practice Address - Phone:202-285-1690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator