Provider Demographics
NPI:1669546859
Name:LONG, ANTHONY RACHE
Entity type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:RACHE
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 1:19428 VIA DEL MAR
Mailing Address - Street 2:APT. 208
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-3054
Mailing Address - Country:US
Mailing Address - Phone:813-391-1074
Mailing Address - Fax:
Practice Address - Street 1:19428 VIA DEL MAR
Practice Address - Street 2:APT. 208
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-3054
Practice Address - Country:US
Practice Address - Phone:813-391-1074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health