Provider Demographics
NPI:1942363429
Name:LONG, LISA JOY (LCSW-C)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:JOY
Last Name:LONG
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12003 CREGGER RD
Mailing Address - Street 2:
Mailing Address - City:KEYMAR
Mailing Address - State:MD
Mailing Address - Zip Code:21757-8131
Mailing Address - Country:US
Mailing Address - Phone:301-325-7989
Mailing Address - Fax:
Practice Address - Street 1:11670 OLD NATIONAL PIKE STE 103
Practice Address - Street 2:
Practice Address - City:NEW MARKET
Practice Address - State:MD
Practice Address - Zip Code:21774-6123
Practice Address - Country:US
Practice Address - Phone:301-865-2226
Practice Address - Fax:301-865-6720
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD126021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical