Provider Demographics
NPI:1366699076
Name:LONG, SALLY (PHD)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 RESERVOIR RD NW
Mailing Address - Street 2:BUILDING D, SUITE 207
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20007-2145
Mailing Address - Country:US
Mailing Address - Phone:202-687-6395
Mailing Address - Fax:
Practice Address - Street 1:600 N. WOLFE ST
Practice Address - Street 2:MEYER 218
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-7218
Practice Address - Country:US
Practice Address - Phone:410-955-0504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-25
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist