Provider Demographics
NPI:1780559930
Name:LONG, MITCHELL II
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:LONG
Suffix:II
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 1:8424 THAMES CT
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198-3650
Mailing Address - Country:US
Mailing Address - Phone:734-845-6793
Mailing Address - Fax:
Practice Address - Street 1:8424 THAMES CT
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48198-3650
Practice Address - Country:US
Practice Address - Phone:734-845-6793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-08
Last Update Date:2025-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker