Provider Demographics
NPI:1689393811
Name:LONG, ALYSSA
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
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 1:606A W KIMBERLY CT
Mailing Address - Street 2:
Mailing Address - City:CLEVER
Mailing Address - State:MO
Mailing Address - Zip Code:65631-7802
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:606A W KIMBERLY CT
Practice Address - Street 2:
Practice Address - City:CLEVER
Practice Address - State:MO
Practice Address - Zip Code:65631-7802
Practice Address - Country:US
Practice Address - Phone:903-920-6477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-23
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker