Provider Demographics
NPI:1619570173
Name:LONG, SHAWN
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:LONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618 HOLCOMB ST APT 7
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:KY
Mailing Address - Zip Code:41143-1258
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1724 S 3RD ST
Practice Address - Street 2:
Practice Address - City:IRONTON
Practice Address - State:OH
Practice Address - Zip Code:45638-2269
Practice Address - Country:US
Practice Address - Phone:740-479-5135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.174773101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)