Provider Demographics
NPI:1295479616
Name:LONG, KAITLYN ELIZABETH (LSW)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:ELIZABETH
Last Name:LONG
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1127 ROUTE 47 S STE 9
Mailing Address - Street 2:
Mailing Address - City:RIO GRANDE
Mailing Address - State:NJ
Mailing Address - Zip Code:08242-1609
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1127 ROUTE 47 S STE 9
Practice Address - Street 2:
Practice Address - City:RIO GRANDE
Practice Address - State:NJ
Practice Address - Zip Code:08242-1609
Practice Address - Country:US
Practice Address - Phone:609-486-2003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-21
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06532700104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker