Provider Demographics
NPI:1730661935
Name:LONG, WANDA MICHELLE (LCSW)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:MICHELLE
Last Name:LONG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:259 E OAKDALE AVE
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32539-3547
Mailing Address - Country:US
Mailing Address - Phone:850-449-9566
Mailing Address - Fax:850-460-8348
Practice Address - Street 1:259 E OAKDALE AVE
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32539-3547
Practice Address - Country:US
Practice Address - Phone:850-682-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW153111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSW15311OtherSTATE OF FLORIDA DEPT OF HEALTH