Provider Demographics
NPI:1881810950
Name:LONG, COREY LYNN (LICSW)
Entity type:Individual
Prefix:MRS
First Name:COREY
Middle Name:LYNN
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 1:70 WAREHAM LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:EAST WAREHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02538-1429
Mailing Address - Country:US
Mailing Address - Phone:508-291-9946
Mailing Address - Fax:
Practice Address - Street 1:543 NORTH ST
Practice Address - Street 2:
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02740-2766
Practice Address - Country:US
Practice Address - Phone:508-984-5566
Practice Address - Fax:508-994-5527
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10287531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPO7323OtherBLUE CROSS BLUE SHIELD
MAP21021Medicare ID - Type Unspecified