Provider Demographics
NPI:1598367369
Name:LONG, GERARD WILLIAM (LMFT)
Entity Type:Individual
Prefix:
First Name:GERARD
Middle Name:WILLIAM
Last Name:LONG
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27075 HOBART RD
Mailing Address - Street 2:
Mailing Address - City:SHINGLETOWN
Mailing Address - State:CA
Mailing Address - Zip Code:96088-9641
Mailing Address - Country:US
Mailing Address - Phone:530-941-0934
Mailing Address - Fax:
Practice Address - Street 1:29632 HWY 299E
Practice Address - Street 2:
Practice Address - City:ROUND MOUNTAIN
Practice Address - State:CA
Practice Address - Zip Code:96084
Practice Address - Country:US
Practice Address - Phone:530-337-6243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC29128106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist