Provider Demographics
NPI:1912401415
Name:LONG, VAKENDALL V (LCSW)
Entity Type:Individual
Prefix:
First Name:VAKENDALL
Middle Name:V
Last Name:LONG
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2220 UNION AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-4315
Mailing Address - Country:US
Mailing Address - Phone:901-567-3554
Mailing Address - Fax:
Practice Address - Street 1:951 COURT AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-2813
Practice Address - Country:US
Practice Address - Phone:901-567-3554
Practice Address - Fax:901-567-3559
Is Sole Proprietor?:No
Enumeration Date:2018-03-20
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN65011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical