Provider Demographics
NPI:1720472756
Name:LONG, PERRY WAYNE (CADC II CA)
Entity Type:Individual
Prefix:MR
First Name:PERRY
Middle Name:WAYNE
Last Name:LONG
Suffix:
Gender:M
Credentials:CADC II CA
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Mailing Address - Street 1:1904 RICHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CERES
Mailing Address - State:CA
Mailing Address - Zip Code:95307-4562
Mailing Address - Country:US
Mailing Address - Phone:209-541-2121
Mailing Address - Fax:209-541-2083
Practice Address - Street 1:1904 RICHLAND AVE
Practice Address - Street 2:
Practice Address - City:CERES
Practice Address - State:CA
Practice Address - Zip Code:95307-4562
Practice Address - Country:US
Practice Address - Phone:209-541-2121
Practice Address - Fax:209-541-2083
Is Sole Proprietor?:No
Enumeration Date:2015-03-27
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)