Basic Information
| Provider Information | |||||||||
| NPI: | 1780011551 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LONG | ||||||||
| FirstName: | LINDSAY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 625 E BROADWAY AVE BOX 428 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 830010428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077333636 | ||||||||
| FaxNumber: | 8883295701 | ||||||||
| Practice Location | |||||||||
| Address1: | 1415 S HWY 89 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 83001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077398999 | ||||||||
| FaxNumber: | 3077399222 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2013 | ||||||||
| LastUpdateDate: | 02/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | LCSW-951 | WY | N | Behavioral Health & Social Service Providers | Social Worker | 171M00000X | WY | N | Other Service Providers | Case Manager/Care Coordinator | 1041C0700X | LCSW-951 | WY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 136295001 | 05 | WY | MEDICAID |