Provider Demographics
NPI:1710936026
Name:LONG, PAUL C (PH D)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:C
Last Name:LONG
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37422-2487
Mailing Address - Country:US
Mailing Address - Phone:423-899-5081
Mailing Address - Fax:423-490-0410
Practice Address - Street 1:6400 LEE HWY
Practice Address - Street 2:ST 110
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-2452
Practice Address - Country:US
Practice Address - Phone:423-899-5081
Practice Address - Fax:423-490-0410
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN1056103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3689042Medicare ID - Type Unspecified