Provider Demographics
NPI:1689926081
Name:KATHRYN C LONGENBARGER
Entity Type:Organization
Organization Name:KATHRYN C LONGENBARGER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:C
Authorized Official - Last Name:LONGENBARGER
Authorized Official - Suffix:
Authorized Official - Credentials:LLPC
Authorized Official - Phone:734-770-2420
Mailing Address - Street 1:845 TANNER LANDING
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48161-4588
Mailing Address - Country:US
Mailing Address - Phone:734-770-2420
Mailing Address - Fax:
Practice Address - Street 1:3554 SOUTH CUSTER ROAD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48161-9774
Practice Address - Country:US
Practice Address - Phone:734-770-2420
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-09
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI640102636101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty