Provider Demographics
NPI:1134606551
Name:LONG, JOHN (CADC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:LONG
Suffix:
Gender:M
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 NW 5TH ST STE 203
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-1869
Mailing Address - Country:US
Mailing Address - Phone:541-516-4087
Mailing Address - Fax:541-504-1195
Practice Address - Street 1:908 NE 4TH ST STE 101
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4646
Practice Address - Country:US
Practice Address - Phone:541-617-7365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-27
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16-12-11101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)