Provider Demographics
NPI:1801120951
Name:LONG, WALTER R (LPC)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:R
Last Name:LONG
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2434 E BLANCHE DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-4313
Mailing Address - Country:US
Mailing Address - Phone:602-456-0340
Mailing Address - Fax:480-571-5367
Practice Address - Street 1:2434 E BLANCHE DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-4313
Practice Address - Country:US
Practice Address - Phone:602-456-0340
Practice Address - Fax:480-571-5367
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-22
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-13843101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ851520Medicaid