Provider Demographics
NPI:1518923655
Name:LONG, GEORGE CLINTON (LMHC)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:CLINTON
Last Name:LONG
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-4304
Mailing Address - Country:US
Mailing Address - Phone:386-236-3225
Mailing Address - Fax:352-291-5588
Practice Address - Street 1:5664 SW 60TH AVE BLDG 2
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34474-5694
Practice Address - Country:US
Practice Address - Phone:800-539-4228
Practice Address - Fax:352-291-5588
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 4520101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ053NOtherBCBS PROVIDER NUMBER
FL761035100Medicaid