Provider Demographics
NPI:1700574092
Name:LONG, PAMELA CARLSON (MSW)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:CARLSON
Last Name:LONG
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2706 N FILLMORE ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52804-1833
Mailing Address - Country:US
Mailing Address - Phone:309-714-1520
Mailing Address - Fax:
Practice Address - Street 1:2550 MIDDLE RD STE 602
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-3289
Practice Address - Country:US
Practice Address - Phone:563-265-1529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-25
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490028971041C0700X
IA0804341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical