Provider Demographics
NPI:1801066774
Name:LONG, GLORIA LEVINE (LICSW)
Entity type:Individual
Prefix:MRS
First Name:GLORIA
Middle Name:LEVINE
Last Name:LONG
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 UNIVERSITY RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-4545
Mailing Address - Country:US
Mailing Address - Phone:617-734-0741
Mailing Address - Fax:
Practice Address - Street 1:135 UNIVERSITY RD
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-4545
Practice Address - Country:US
Practice Address - Phone:617-734-0741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-07
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1032521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA70010000P05052OtherBLUE CROSS BLUE SHIELD