Provider Demographics
NPI:1184095531
Name:LONG, TESI TAYLOR (ASW91680)
Entity type:Individual
Prefix:
First Name:TESI
Middle Name:TAYLOR
Last Name:LONG
Suffix:
Gender:F
Credentials:ASW91680
Other - Prefix:
Other - First Name:TESI
Other - Middle Name:TAYLOR
Other - Last Name:KEEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:33100 COUNTY ROAD 31
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-9523
Mailing Address - Country:US
Mailing Address - Phone:530-702-6000
Mailing Address - Fax:
Practice Address - Street 1:33100 COUNTY ROAD 31
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-9523
Practice Address - Country:US
Practice Address - Phone:530-702-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-12
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CA1100381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)