Provider Demographics
NPI:1245696558
Name:LONG, AMY RENEE (LPC)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:RENEE
Last Name:LONG
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1659 FARLEY DR
Mailing Address - Street 2:
Mailing Address - City:TUNNEL HILL
Mailing Address - State:GA
Mailing Address - Zip Code:30755-7769
Mailing Address - Country:US
Mailing Address - Phone:423-802-9080
Mailing Address - Fax:
Practice Address - Street 1:2406 CLEVELAND HWY
Practice Address - Street 2:SUITE 305
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30721-8155
Practice Address - Country:US
Practice Address - Phone:706-277-4883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-04
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC007501101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional