Provider Demographics
NPI:1487865226
Name:LONG, KRISTIN MARY
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:MARY
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 SAN PABLO AVE STE 8
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:CA
Mailing Address - Zip Code:94706-2277
Mailing Address - Country:US
Mailing Address - Phone:510-423-2846
Mailing Address - Fax:
Practice Address - Street 1:1035 SAN PABLO AVE STE 8
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:CA
Practice Address - Zip Code:94706-2277
Practice Address - Country:US
Practice Address - Phone:510-423-2846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 47560106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist