Basic Information
| Provider Information | |||||||||
| NPI: | 1720561806 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LONG | ||||||||
| FirstName: | PENNY | ||||||||
| MiddleName: | KATHLEEN | ||||||||
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| Credential: | CDPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 121 NW CHEHALIS AVE | ||||||||
| Address2: | |||||||||
| City: | CHEHALIS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985322010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607409767 | ||||||||
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| Practice Location | |||||||||
| Address1: | 121 NW CHEHALIS AVE | ||||||||
| Address2: | |||||||||
| City: | CHEHALIS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985322010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607409767 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2018 | ||||||||
| LastUpdateDate: | 09/13/2018 | ||||||||
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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 | 101YA0400X | 60804582 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 60804582 | 01 | WA | DEPT OF HEALTH | OTHER |