Provider Demographics
NPI:1790366193
Name:LONG INTEGRATED PSYCHIATRIC SERVICES LLC
Entity Type:Organization
Organization Name:LONG INTEGRATED PSYCHIATRIC SERVICES LLC
Other - Org Name:LONG INTEGRATED PSYCHIATRIC SERVICES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:410-508-0722
Mailing Address - Street 1:11560 CROSSROADS CIR STE 102
Mailing Address - Street 2:
Mailing Address - City:MIDDLE RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:21220-2885
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11560 CROSSROADS CIR
Practice Address - Street 2:
Practice Address - City:MIDDLE RIVER
Practice Address - State:MD
Practice Address - Zip Code:21220-2885
Practice Address - Country:US
Practice Address - Phone:410-508-0722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-16
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty