Provider Demographics
NPI:1902375652
Name:LONG, EDGAR CHARLES JOHN (PHD)
Entity Type:Individual
Prefix:DR
First Name:EDGAR
Middle Name:CHARLES JOHN
Last Name:LONG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2163 CORNERSTONE DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-8029
Mailing Address - Country:US
Mailing Address - Phone:989-330-2417
Mailing Address - Fax:
Practice Address - Street 1:2163 CORNERSTONE DR
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-8029
Practice Address - Country:US
Practice Address - Phone:989-330-2417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-23
Last Update Date:2018-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
MI4101005371103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamilyGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty