Provider Demographics
NPI:1669538237
Name:LONG, SHIRLEY L (EDD)
Entity type:Individual
Prefix:DR
First Name:SHIRLEY
Middle Name:L
Last Name:LONG
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4921 PROCTOR AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94618-2544
Mailing Address - Country:US
Mailing Address - Phone:408-987-0999
Mailing Address - Fax:408-996-2877
Practice Address - Street 1:4921 PROCTOR AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94618-2544
Practice Address - Country:US
Practice Address - Phone:408-987-0999
Practice Address - Fax:408-996-2877
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY11791103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical