Provider Demographics
NPI:1720134844
Name:LONG, WANDA KAYE (LCSW, LIMHP)
Entity Type:Individual
Prefix:MS
First Name:WANDA
Middle Name:KAYE
Last Name:LONG
Suffix:
Gender:F
Credentials:LCSW, LIMHP
Other - Prefix:MS
Other - First Name:WANDA
Other - Middle Name:KAYE
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW, LIMHP
Mailing Address - Street 1:1811 W 2ND ST STE 450
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-5473
Mailing Address - Country:US
Mailing Address - Phone:308-382-8085
Mailing Address - Fax:308-339-0962
Practice Address - Street 1:1811 W 2ND ST STE 450
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-5473
Practice Address - Country:US
Practice Address - Phone:308-382-8085
Practice Address - Fax:308-382-8085
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE787101YM0800X
NE5111041C0700X
NE320,787101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47072149413Medicaid
82143OtherBCBS
NE100260989-00Medicaid
8582OtherMIDLANDS CHOICE
8582OtherMIDLANDS CHOICE