Provider Demographics
NPI:1508056045
Name:LONG, GERI ANNE (CDP)
Entity Type:Individual
Prefix:
First Name:GERI
Middle Name:ANNE
Last Name:LONG
Suffix:
Gender:F
Credentials:CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14148 TILLEY RD S
Mailing Address - Street 2:
Mailing Address - City:TENINO
Mailing Address - State:WA
Mailing Address - Zip Code:98589-9222
Mailing Address - Country:US
Mailing Address - Phone:509-990-8775
Mailing Address - Fax:
Practice Address - Street 1:4800 COLLEGE ST SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-4389
Practice Address - Country:US
Practice Address - Phone:509-990-8775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-31
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00054823101YA0400X
WACP60027739101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)