Provider Demographics
NPI:1821234964
Name:LONG, HOLLY REBECCA (PC)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:REBECCA
Last Name:LONG
Suffix:
Gender:F
Credentials:PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 867
Mailing Address - Street 2:105 WEST 100 NORTH
Mailing Address - City:PRICE
Mailing Address - State:UT
Mailing Address - Zip Code:84501
Mailing Address - Country:US
Mailing Address - Phone:435-637-7200
Mailing Address - Fax:435-637-2377
Practice Address - Street 1:198 EAST CENTER STREET
Practice Address - Street 2:
Practice Address - City:MOAB
Practice Address - State:UT
Practice Address - Zip Code:84532
Practice Address - Country:US
Practice Address - Phone:435-259-6131
Practice Address - Fax:435-259-5369
Is Sole Proprietor?:No
Enumeration Date:2008-12-19
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7109900-6004101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional