Provider Demographics
NPI:1659971802
Name:LONG, LAUREN ANTOINETTE (LLPC)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:ANTOINETTE
Last Name:LONG
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:732 E GRAND BLANC RD
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-1333
Mailing Address - Country:US
Mailing Address - Phone:810-771-5102
Mailing Address - Fax:
Practice Address - Street 1:732 E GRAND BLANC RD
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-1333
Practice Address - Country:US
Practice Address - Phone:810-771-5102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401018589101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health