Provider Demographics
NPI:1689264251
Name:LONG, MELINDA LEE
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:LEE
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 1:1133 STEWARTS WAY
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19154-1650
Mailing Address - Country:US
Mailing Address - Phone:267-825-3198
Mailing Address - Fax:
Practice Address - Street 1:218 TRIANON LN
Practice Address - Street 2:
Practice Address - City:VILLANOVA
Practice Address - State:PA
Practice Address - Zip Code:19085-1442
Practice Address - Country:US
Practice Address - Phone:215-548-9632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-19
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician