Provider Demographics
NPI:1801019021
Name:LONG, PETER FRANCIS (PSYD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:FRANCIS
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 1:950 WADSWORTH BLVD
Mailing Address - Street 2:SUITE 304
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80214-4542
Mailing Address - Country:US
Mailing Address - Phone:303-232-9102
Mailing Address - Fax:303-232-9074
Practice Address - Street 1:950 WADSWORTH BLVD
Practice Address - Street 2:SUITE 304
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80214-4542
Practice Address - Country:US
Practice Address - Phone:303-232-9102
Practice Address - Fax:303-232-9074
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1216103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO068968OtherVALUE OPTIONS PROVIDER #
CO07012164Medicaid
COC88826Medicare PIN