Provider Demographics
NPI:1356129217
Name:LONG, OCTAVIS LAQUAN
Entity type:Individual
Prefix:
First Name:OCTAVIS
Middle Name:LAQUAN
Last Name:LONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 BUTEO DR
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-8304
Mailing Address - Country:US
Mailing Address - Phone:517-614-5200
Mailing Address - Fax:
Practice Address - Street 1:715 BUTEO DR
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-8304
Practice Address - Country:US
Practice Address - Phone:517-614-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-20
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361002091103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist