Provider Demographics
NPI:1447592555
Name:DE LONG, THERESA (MFT)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:DE LONG
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2730 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 660
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403
Mailing Address - Country:US
Mailing Address - Phone:310-383-0779
Mailing Address - Fax:310-410-9507
Practice Address - Street 1:2730 WILSHIRE BLVD
Practice Address - Street 2:SUITE 660
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403
Practice Address - Country:US
Practice Address - Phone:310-383-0779
Practice Address - Fax:310-410-9507
Is Sole Proprietor?:No
Enumeration Date:2013-03-27
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFC 52307OtherLICENSE