Provider Demographics
NPI:1255521696
Name:LONG, LAQUENTA MARZETT
Entity type:Individual
Prefix:
First Name:LAQUENTA
Middle Name:MARZETT
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8350 ARCHIBALD AVE
Mailing Address - Street 2:SUITE125
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-3669
Mailing Address - Country:US
Mailing Address - Phone:909-559-3853
Mailing Address - Fax:
Practice Address - Street 1:8350 ARCHIBALD AVE
Practice Address - Street 2:SUITE125
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3669
Practice Address - Country:US
Practice Address - Phone:909-559-3853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-01
Last Update Date:2014-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53992106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist