Provider Demographics
NPI:1720747322
Name:LONG, EDWARD C III
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:C
Last Name:LONG
Suffix:III
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 1:901 N BLAINE ST
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-5006
Mailing Address - Country:US
Mailing Address - Phone:765-716-1556
Mailing Address - Fax:
Practice Address - Street 1:1715 N GRANVILL AVE SUITE C
Practice Address - Street 2:MUNCIE
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-4730
Practice Address - Country:US
Practice Address - Phone:765-749-7300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-10
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health