Provider Demographics
NPI:1508577800
Name:LONG, BRIAN J (BA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
Last Name:LONG
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4085 N VAN NUYS RD
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-2544
Mailing Address - Country:US
Mailing Address - Phone:928-377-0453
Mailing Address - Fax:
Practice Address - Street 1:1850 GATES AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-8003
Practice Address - Country:US
Practice Address - Phone:928-377-0453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-07
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ22972101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral