Provider Demographics
NPI:1831891365
Name:LONG, ALTAVIA (ABA THERAPIST)
Entity type:Individual
Prefix:MS
First Name:ALTAVIA
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:ABA THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4345 4TH ST SE APT 3
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20032-3382
Mailing Address - Country:US
Mailing Address - Phone:202-618-2049
Mailing Address - Fax:
Practice Address - Street 1:60 O ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20001-1259
Practice Address - Country:US
Practice Address - Phone:202-797-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-20
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
CA0000822461103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty