Basic Information
| Provider Information | |||||||||
| NPI: | 1134606551 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LONG | ||||||||
| FirstName: | JOHN | ||||||||
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| Credential: | CADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 340 NW 5TH ST STE 203 | ||||||||
| Address2: | |||||||||
| City: | REDMOND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977561869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415164087 | ||||||||
| FaxNumber: | 5415041195 | ||||||||
| Practice Location | |||||||||
| Address1: | 908 NE 4TH ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977014646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416177365 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2018 | ||||||||
| LastUpdateDate: | 07/27/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 16-12-11 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.