Provider Demographics
NPI:1659381036
Name:LONG, JUDY (MSW)
Entity Type:Individual
Prefix:MRS
First Name:JUDY
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:713 6TH ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-4359
Mailing Address - Country:US
Mailing Address - Phone:505-425-6126
Mailing Address - Fax:505-425-6236
Practice Address - Street 1:713 6TH ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4359
Practice Address - Country:US
Practice Address - Phone:505-425-6126
Practice Address - Fax:505-425-6236
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI01111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical