Basic Information
| Provider Information | |||||||||
| NPI: | 1821587395 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LONG | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Credential: | LSW, CDCA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 248 S HEINCKE RD APT 5H | ||||||||
| Address2: | |||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453423577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372045015 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5900 W CHESTER RD STE C | ||||||||
| Address2: | |||||||||
| City: | WEST CHESTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450692951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137772428 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2018 | ||||||||
| LastUpdateDate: | 05/09/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | S.1302793 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.