Provider Demographics
NPI:1861855116
Name:LONG, INGRID (LMSW)
Entity Type:Individual
Prefix:
First Name:INGRID
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:INGRID
Other - Middle Name:JANELLE
Other - Last Name:FOX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:180 10TH ST SE STE 201
Mailing Address - Street 2:PO BOX 70
Mailing Address - City:LE MARS
Mailing Address - State:IA
Mailing Address - Zip Code:51031-2557
Mailing Address - Country:US
Mailing Address - Phone:712-546-4624
Mailing Address - Fax:712-546-9395
Practice Address - Street 1:180 10TH ST SE STE 201
Practice Address - Street 2:
Practice Address - City:LE MARS
Practice Address - State:IA
Practice Address - Zip Code:51031-2557
Practice Address - Country:US
Practice Address - Phone:712-546-4624
Practice Address - Fax:712-546-9395
Is Sole Proprietor?:No
Enumeration Date:2016-04-04
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA080125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health