Provider Demographics
NPI:1467171363
Name:DR. AIXA LONG
Entity Type:Organization
Organization Name:DR. AIXA LONG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AIXA
Authorized Official - Middle Name:
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:813-784-7340
Mailing Address - Street 1:9807 PEPPER TREE PLACE
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:34785
Mailing Address - Country:US
Mailing Address - Phone:813-784-7340
Mailing Address - Fax:
Practice Address - Street 1:601 WEBSTER ST
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:FL
Practice Address - Zip Code:34785-3828
Practice Address - Country:US
Practice Address - Phone:352-432-8892
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-24
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty