Provider Demographics
NPI:1770077091
Name:LONG, RISA NICOLE (PHD)
Entity type:Individual
Prefix:DR
First Name:RISA
Middle Name:NICOLE
Last Name:LONG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 ACKERMAN RD STE 2120
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1559
Mailing Address - Country:US
Mailing Address - Phone:614-293-5123
Mailing Address - Fax:
Practice Address - Street 1:543 TAYLOR AVE FL 2
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43203-1278
Practice Address - Country:US
Practice Address - Phone:614-293-5123
Practice Address - Fax:614-293-4980
Is Sole Proprietor?:No
Enumeration Date:2018-06-20
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHP.07733103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical