Provider Demographics
NPI:1942600606
Name:TIMOTHY D LONG, LMFT
Entity Type:Organization
Organization Name:TIMOTHY D LONG, LMFT
Other - Org Name:KAINOS CHRISTIAN THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:D
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT, LPCC
Authorized Official - Phone:310-203-1510
Mailing Address - Street 1:329 N WETHERLY DR
Mailing Address - Street 2:SUITE 206
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-1605
Mailing Address - Country:US
Mailing Address - Phone:310-203-1510
Mailing Address - Fax:
Practice Address - Street 1:329 N WETHERLY DR
Practice Address - Street 2:SUITE 206
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-1605
Practice Address - Country:US
Practice Address - Phone:310-203-1510
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-01
Last Update Date:2014-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALPCC1152101YP2500X
CA47459106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty