Provider Demographics
NPI:1508846213
Name:LONG, JOHN WESLEY (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WESLEY
Last Name:LONG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:118 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:STANLEY
Mailing Address - State:NC
Mailing Address - Zip Code:28164-1202
Mailing Address - Country:US
Mailing Address - Phone:704-263-0425
Mailing Address - Fax:704-861-0374
Practice Address - Street 1:1530 UNION RD STE A
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2201
Practice Address - Country:US
Practice Address - Phone:704-861-0271
Practice Address - Fax:704-861-0374
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC0463103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC249030BMedicare PIN