Provider Demographics
NPI:1720564933
Name:DAWN LEA LONG COUNSELING LLC
Entity Type:Organization
Organization Name:DAWN LEA LONG COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR/ COUNSELOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:LEA
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:MHR LADC LBHP
Authorized Official - Phone:405-863-2602
Mailing Address - Street 1:5350 S WESTERN AVE STE 211
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73109-4525
Mailing Address - Country:US
Mailing Address - Phone:405-863-2602
Mailing Address - Fax:
Practice Address - Street 1:5350 S WESTERN AVE STE 211
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109-4525
Practice Address - Country:US
Practice Address - Phone:405-863-2602
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1213101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200386090BMedicaid