Basic Information
| Provider Information | |||||||||
| NPI: | 1871588178 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LONG | ||||||||
| FirstName: | SONDRA | ||||||||
| MiddleName: | ADELE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 730 FAIRWAY DR | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329407020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3212420525 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1381 S PATRICK DR | ||||||||
| Address2: | BLDG 1370 LIFE SKILLS SUPPORT CENTER 45 MDOS SGOH | ||||||||
| City: | PATRICK AFB | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329253606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3214948234 | ||||||||
| FaxNumber: | 3214948074 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | SW 4492 | FL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.