Provider Demographics
NPI:1912416561
Name:LONG, MICHAEL PAUL (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PAUL
Last Name:LONG
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14523 WESTLAKE DRIVE, LAKE OSWEGO, OR 97035
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035
Mailing Address - Country:US
Mailing Address - Phone:971-280-0370
Mailing Address - Fax:
Practice Address - Street 1:14523 WESTLAKE DRIVE, LAKE OSWEGO, OR 97035
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035
Practice Address - Country:US
Practice Address - Phone:971-280-0370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL67581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORL6758OtherLICENSED CLINICAL SOCIAL WORKER