Provider Demographics
NPI:1588819551
Name:BEVERLY JEAN LONG
Entity type:Organization
Organization Name:BEVERLY JEAN LONG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT/BILLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANET
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MEULEMANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-307-7865
Mailing Address - Street 1:546 WINONA ST E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55107-2425
Mailing Address - Country:US
Mailing Address - Phone:651-253-8438
Mailing Address - Fax:
Practice Address - Street 1:1595 SELBY AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-6221
Practice Address - Country:US
Practice Address - Phone:651-253-8438
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-18
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1680103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNCO4633Medicare PIN