Provider Demographics
NPI:1609396100
Name:LONGMIRE, MONETTE IDNANI
Entity Type:Individual
Prefix:
First Name:MONETTE
Middle Name:IDNANI
Last Name:LONGMIRE
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 1:4755 SPICE ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93536-2377
Mailing Address - Country:US
Mailing Address - Phone:805-559-4229
Mailing Address - Fax:
Practice Address - Street 1:4755 SPICE ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93536-2377
Practice Address - Country:US
Practice Address - Phone:805-559-4229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR12446590217101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)