Provider Demographics
NPI:1679190607
Name:LONG, CAMERYN N
Entity Type:Individual
Prefix:
First Name:CAMERYN
Middle Name:N
Last Name:LONG
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 1:4471 STONERIDGE DR STE A
Mailing Address - Street 2:
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94588-8403
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4471 STONERIDGE DR STE A
Practice Address - Street 2:
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94588-8403
Practice Address - Country:US
Practice Address - Phone:925-425-9071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-25
Last Update Date:2023-08-06
Deactivation Date:2023-07-13
Deactivation Code:
Reactivation Date:2023-08-02
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CA17919235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician