Provider Demographics
NPI:1700924826
Name:LONG, ESTELA (ESTELITA) M (PSY D)
Entity Type:Individual
Prefix:DR
First Name:ESTELA (ESTELITA)
Middle Name:M
Last Name:LONG
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:934 CYPRESS VILLAGE BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:RUSKIN
Mailing Address - State:FL
Mailing Address - Zip Code:33573-6832
Mailing Address - Country:US
Mailing Address - Phone:813-634-4700
Mailing Address - Fax:813-634-4703
Practice Address - Street 1:4020 SUN CITY CENTER BLVD.
Practice Address - Street 2:SUITE 11
Practice Address - City:SUN CITY CENTER
Practice Address - State:FL
Practice Address - Zip Code:33573-5256
Practice Address - Country:US
Practice Address - Phone:813-634-4700
Practice Address - Fax:813-634-4703
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2016-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 6533103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU6834-AMedicare ID - Type Unspecified