Provider Demographics
NPI:1851033252
Name:LONG, ANGELA (LSW)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 ROLLING RD
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-4125
Mailing Address - Country:US
Mailing Address - Phone:732-616-6550
Mailing Address - Fax:
Practice Address - Street 1:18 CAMPUS BLVD STE 100
Practice Address - Street 2:
Practice Address - City:NEWTOWN SQUARE
Practice Address - State:PA
Practice Address - Zip Code:19073-3240
Practice Address - Country:US
Practice Address - Phone:267-995-4065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-07
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06648200101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health