Provider Demographics
NPI:1184719841
Name:LONG, NANCY B (LCSW)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:B
Last Name:LONG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:NANCY
Other - Middle Name:V
Other - Last Name:BARTHOLOMEW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3111 MAPLEWOOD AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-3906
Mailing Address - Country:US
Mailing Address - Phone:336-659-8817
Mailing Address - Fax:
Practice Address - Street 1:3111 MAPLEWOOD AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3906
Practice Address - Country:US
Practice Address - Phone:336-659-8817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0025401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6106852Medicaid
NC6003256Medicaid
NC6003256Medicaid