Provider Demographics
NPI:1568137594
Name:DELONG, GABRIEL ASHAR
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:ASHAR
Last Name:DELONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3675 THREE MILE DR
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-3603
Mailing Address - Country:US
Mailing Address - Phone:770-367-1663
Mailing Address - Fax:
Practice Address - Street 1:17177 N LAUREL PARK DR
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-2693
Practice Address - Country:US
Practice Address - Phone:734-462-3210
Practice Address - Fax:734-462-1024
Is Sole Proprietor?:No
Enumeration Date:2021-08-11
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6352000616103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist