Basic Information
| Provider Information | |||||||||
| NPI: | 1962013318 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LONGO | ||||||||
| FirstName: | LEE ANN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16314 CORNUTA AVE | ||||||||
| Address2: | |||||||||
| City: | BELLFLOWER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907064814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624619272 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 16314 CORNUTA AVE | ||||||||
| Address2: | |||||||||
| City: | BELLFLOWER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907064814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624619272 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2020 | ||||||||
| LastUpdateDate: | 08/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | R1359290819 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | R1359290819 | 01 | CA | REGISTERED ALCOHOL DRUG TECHNICIAN | OTHER |