Provider Demographics
NPI:1821587395
Name:LONG, SAMUEL ROBERT (LSW, CDCA)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:ROBERT
Last Name:LONG
Suffix:
Gender:M
Credentials:LSW, CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:248 S HEINCKE RD APT 5H
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-3577
Mailing Address - Country:US
Mailing Address - Phone:937-204-5015
Mailing Address - Fax:
Practice Address - Street 1:5900 W CHESTER RD STE C
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:OH
Practice Address - Zip Code:45069-2951
Practice Address - Country:US
Practice Address - Phone:513-777-2428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-09
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1302793104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker