Provider Demographics
NPI:1689399107
Name:LONGO, ALEXIS R (LAC)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:R
Last Name:LONGO
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:ALI
Other - Middle Name:
Other - Last Name:LONGO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:70 PARK ST STE 104
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-2960
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:70 PARK ST STE 104
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-2960
Practice Address - Country:US
Practice Address - Phone:862-234-5029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-06
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health