Provider Demographics
NPI:1598197535
Name:LONG, LAKITA RENELL (LPC)
Entity Type:Individual
Prefix:MRS
First Name:LAKITA
Middle Name:RENELL
Last Name:LONG
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8236
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31095-8236
Mailing Address - Country:US
Mailing Address - Phone:478-302-3135
Mailing Address - Fax:
Practice Address - Street 1:314 WOODS TRL
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:GA
Practice Address - Zip Code:31069-9251
Practice Address - Country:US
Practice Address - Phone:478-302-3135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-01
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006745101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health