Provider Demographics
NPI:1356525810
Name:LONG, MELINDA JANE (LPC)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:JANE
Last Name:LONG
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 WHIPOORWILL WAY
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-2621
Mailing Address - Country:US
Mailing Address - Phone:478-998-2171
Mailing Address - Fax:478-296-1214
Practice Address - Street 1:104 WHIPOORWILL WAY
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-2621
Practice Address - Country:US
Practice Address - Phone:478-998-2171
Practice Address - Fax:478-296-1214
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-19
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5127101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health