Provider Demographics
NPI:1295462505
Name:LONG, BROOKELYNN (LMSW)
Entity type:Individual
Prefix:
First Name:BROOKELYNN
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 W MAIN ST STE 101
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-2803
Mailing Address - Country:US
Mailing Address - Phone:479-968-2001
Mailing Address - Fax:
Practice Address - Street 1:1 LILE CT STE 200
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6240
Practice Address - Country:US
Practice Address - Phone:501-663-1837
Practice Address - Fax:501-663-1839
Is Sole Proprietor?:No
Enumeration Date:2022-08-05
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR11978-M104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker