Provider Demographics
NPI:1255423927
Name:LONG, J. DAVID (PSYCHOLOGIST DOCTORA)
Entity type:Individual
Prefix:MR
First Name:J.
Middle Name:DAVID
Last Name:LONG
Suffix:
Gender:M
Credentials:PSYCHOLOGIST DOCTORA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 686
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05753-0686
Mailing Address - Country:US
Mailing Address - Phone:802-352-9085
Mailing Address - Fax:
Practice Address - Street 1:78 S MAIN ST
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4530
Practice Address - Country:US
Practice Address - Phone:802-775-8224
Practice Address - Fax:802-747-7699
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0480000309103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT9963OtherBC/BS
VT9534Medicaid
VTVT9534Medicare ID - Type Unspecified