Provider Demographics
NPI:1801382015
Name:LONG, SCOTT
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:LONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 E. WASHINGTON STREET
Mailing Address - Street 2:
Mailing Address - City:PANDORA
Mailing Address - State:OH
Mailing Address - Zip Code:45877
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5726 SOUTHWYCK BLVD STE 200
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-1510
Practice Address - Country:US
Practice Address - Phone:419-865-5690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health