Provider Demographics
NPI:1740271337
Name:LONG, CHARLES ANTHONY (MFT)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:ANTHONY
Last Name:LONG
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5480 BALTIMORE DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942
Mailing Address - Country:US
Mailing Address - Phone:619-462-0199
Mailing Address - Fax:619-464-7772
Practice Address - Street 1:5480 BALTIMORE DR
Practice Address - Street 2:SUITE 202
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942
Practice Address - Country:US
Practice Address - Phone:619-462-0199
Practice Address - Fax:619-464-7772
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33504106H00000X
CAMFC33504106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist