Provider Demographics
NPI:1477836799
Name:LONG, LORI (PHD, NCSP)
Entity Type:Individual
Prefix:DR
First Name:LORI
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:PHD, NCSP
Other - Prefix:MISS
Other - First Name:LORI
Other - Middle Name:ANN
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7600 N 16TH ST
Mailing Address - Street 2:SUITE 218
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-4431
Mailing Address - Country:US
Mailing Address - Phone:602-904-3405
Mailing Address - Fax:
Practice Address - Street 1:7600 N 16TH ST
Practice Address - Street 2:SUITE 218
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-4431
Practice Address - Country:US
Practice Address - Phone:602-904-3405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-22
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4207103TB0200X, 103TM1800X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities