Provider Demographics
NPI:1265876940
Name:LONG, ANNETTE ELISE (MEDS)
Entity type:Individual
Prefix:MS
First Name:ANNETTE
Middle Name:ELISE
Last Name:LONG
Suffix:
Gender:F
Credentials:MEDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4303 CENTRAL AVENUE PIKE
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37912-4310
Mailing Address - Country:US
Mailing Address - Phone:865-247-7045
Mailing Address - Fax:865-249-8458
Practice Address - Street 1:4303 CENTRAL AVE.PIKE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37912
Practice Address - Country:US
Practice Address - Phone:865-247-7045
Practice Address - Fax:865-249-8458
Is Sole Proprietor?:No
Enumeration Date:2013-04-24
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN101YM0800X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker