Provider Demographics
NPI:1356189542
Name:LONG, PHOENYX DESHUN (MS)
Entity type:Individual
Prefix:
First Name:PHOENYX
Middle Name:DESHUN
Last Name:LONG
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:MALENNA
Other - Middle Name:
Other - Last Name:SAUNDERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:148 W 141ST ST APT C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10030-1880
Mailing Address - Country:US
Mailing Address - Phone:214-732-4776
Mailing Address - Fax:
Practice Address - Street 1:1582 E 22ND ST APT 4R
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-5120
Practice Address - Country:US
Practice Address - Phone:214-732-4776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-20
Last Update Date:2024-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP129669101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health