Provider Demographics
NPI:1942218698
Name:LONGO, DEBRA MOFFAT (LMSW)
Entity Type:Individual
Prefix:MS
First Name:DEBRA
Middle Name:MOFFAT
Last Name:LONGO
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2727 JENNINGS RD
Mailing Address - Street 2:
Mailing Address - City:WHITMORE LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48189-9266
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3145 W CLARK RD
Practice Address - Street 2:SUITE #201
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1120
Practice Address - Country:US
Practice Address - Phone:734-528-5700
Practice Address - Fax:734-528-8008
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010637691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN70790042Medicare PIN