Provider Demographics
NPI:1841861085
Name:LONG, MAXINE
Entity type:Individual
Prefix:
First Name:MAXINE
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2623 5TH ST N
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-2009
Mailing Address - Country:US
Mailing Address - Phone:662-241-7097
Mailing Address - Fax:662-245-0511
Practice Address - Street 1:2623 5TH ST N
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-2009
Practice Address - Country:US
Practice Address - Phone:662-241-7097
Practice Address - Fax:662-245-0511
Is Sole Proprietor?:No
Enumeration Date:2021-07-08
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
MS101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional