Basic Information
| Provider Information | |||||||||
| NPI: | 1831458561 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LONG | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | DE WAYNE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMHC, LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 630 TEJON AVE SW | ||||||||
| Address2: | |||||||||
| City: | PALM BAY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329087437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3214829492 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 870 HOLLYWOOD BLVD | ||||||||
| Address2: | |||||||||
| City: | WEST MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329047418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004381772 | ||||||||
| FaxNumber: | 2623455562 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2012 | ||||||||
| LastUpdateDate: | 08/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | MH 11075 | FL | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 5617-125 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 100057489 | 05 | WI | MEDICAID |