Provider Demographics
NPI:1902813819
Name:LONGO, LISA MARIE (MAED/WSC)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:LONGO
Suffix:
Gender:F
Credentials:MAED/WSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 DESOTO AVE
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33936-8113
Mailing Address - Country:US
Mailing Address - Phone:239-303-2900
Mailing Address - Fax:239-303-2909
Practice Address - Street 1:814 DESOTO AVE
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33936-8113
Practice Address - Country:US
Practice Address - Phone:239-303-2900
Practice Address - Fax:239-303-2909
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL682566496Medicaid