Provider Demographics
NPI:1699826412
Name:LONG, ANGELA DALE (LICSW)
Entity Type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:DALE
Last Name:LONG
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 TRAFALGAR SQ STE 204
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03063-1998
Mailing Address - Country:US
Mailing Address - Phone:603-577-5517
Mailing Address - Fax:603-402-3551
Practice Address - Street 1:1 TRAFALGAR SQ STE 204
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03063-1998
Practice Address - Country:US
Practice Address - Phone:603-577-5517
Practice Address - Fax:603-402-3551
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH9801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH51-0566390OtherCIGNA
NH385828OtherMVP
NH51-0566390-01OtherPACIFICARE
NH30424141Medicaid
NH14Y001084NH03OtherBLUE CROSS BLUE SHIELD