Provider Demographics
NPI:1790336998
Name:LONG, MICHAEL THOMAS (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:THOMAS
Last Name:LONG
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 CHESTER PIKE
Mailing Address - Street 2:
Mailing Address - City:SHARON HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19079-1411
Mailing Address - Country:US
Mailing Address - Phone:610-312-4776
Mailing Address - Fax:
Practice Address - Street 1:921 CHESTER PIKE
Practice Address - Street 2:
Practice Address - City:SHARON HILL
Practice Address - State:PA
Practice Address - Zip Code:19079-1411
Practice Address - Country:US
Practice Address - Phone:610-312-4776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-27
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS018844103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty