Provider Demographics
NPI:1265408124
Name:LONG, MARK A D (EDD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:A D
Last Name:LONG
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:249 W YORK ST
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23510-1520
Mailing Address - Country:US
Mailing Address - Phone:757-622-6794
Mailing Address - Fax:757-626-1509
Practice Address - Street 1:249 W YORK ST
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23510-1520
Practice Address - Country:US
Practice Address - Phone:757-622-6794
Practice Address - Fax:757-626-1509
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810001510103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical