Basic Information
| Provider Information | |||||||||
| NPI: | 1619981008 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LONG | ||||||||
| FirstName: | LEE | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 34 | ||||||||
| Address2: | |||||||||
| City: | SAINT CHARLES | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721400034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702823113 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2410 HWY 65 N | ||||||||
| Address2: | DEETA COUNSELING ASSOCIATES INC | ||||||||
| City: | MCGEHEE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 71654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702223107 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 1672C | AR | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 50088 | 01 | AR | BCBS | OTHER |