Provider Demographics
NPI:1912033523
Name:LONGEST, MIRYAM (PHD)
Entity Type:Individual
Prefix:DR
First Name:MIRYAM
Middle Name:
Last Name:LONGEST
Suffix:
Gender:F
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:PO BOX 710430
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92171-0430
Mailing Address - Country:US
Mailing Address - Phone:619-326-9513
Mailing Address - Fax:
Practice Address - Street 1:3131 CAMINO DEL RIO N STE 400
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108
Practice Address - Country:US
Practice Address - Phone:619-326-9513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19900103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical