Provider Demographics
NPI:1720561806
Name:LONG, PENNY KATHLEEN (CDPT)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:KATHLEEN
Last Name:LONG
Suffix:
Gender:F
Credentials:CDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 NW CHEHALIS AVE
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-2010
Mailing Address - Country:US
Mailing Address - Phone:360-740-9767
Mailing Address - Fax:
Practice Address - Street 1:121 NW CHEHALIS AVE
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-2010
Practice Address - Country:US
Practice Address - Phone:360-740-9767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-13
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60804582101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA60804582OtherDEPT OF HEALTH