Provider Demographics
NPI:1508957838
Name:LONG, MATT (BA)
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:
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 1:45 EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2337
Mailing Address - Country:US
Mailing Address - Phone:731-664-2083
Mailing Address - Fax:731-664-1988
Practice Address - Street 1:45 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2337
Practice Address - Country:US
Practice Address - Phone:731-664-2083
Practice Address - Fax:731-664-1988
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor