Provider Demographics
NPI:1588217517
Name:NGUYEN, LONG
Entity Type:Individual
Prefix:
First Name:LONG
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8615 E VILLAGE AVE
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY VILLAGE
Mailing Address - State:MD
Mailing Address - Zip Code:20886-4316
Mailing Address - Country:US
Mailing Address - Phone:240-912-2220
Mailing Address - Fax:301-926-9384
Practice Address - Street 1:8615 E VILLAGE AVE
Practice Address - Street 2:
Practice Address - City:MONTGOMERY VILLAGE
Practice Address - State:MD
Practice Address - Zip Code:20886-4316
Practice Address - Country:US
Practice Address - Phone:240-912-2220
Practice Address - Fax:301-926-9384
Is Sole Proprietor?:No
Enumeration Date:2019-07-18
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDRBT-19-75757106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician