Provider Demographics
NPI:1629102124
Name:LONG, MARY MARGARET (LCPC, MAC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MARGARET
Last Name:LONG
Suffix:
Gender:F
Credentials:LCPC, MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CMR 450 BOX 1213
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09705-0013
Mailing Address - Country:US
Mailing Address - Phone:326-536-4377
Mailing Address - Fax:
Practice Address - Street 1:AVENUE D'OSLO BLDG 401
Practice Address - Street 2:UNIT 21420
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09705
Practice Address - Country:US
Practice Address - Phone:314-566-5320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
501904101YA0400X
IDLCPC-3666101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002269500Medicaid
ID000010146797OtherREGENCE BLUE SHIELD
IDQ7358OtherBLUE CROSS OF IDAHO