Provider Demographics
NPI:1487621850
Name:LONGO, DAVID J (PHD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:J
Last Name:LONGO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 MILL ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17821-1015
Mailing Address - Country:US
Mailing Address - Phone:570-271-1995
Mailing Address - Fax:
Practice Address - Street 1:502 MILL ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17821-1015
Practice Address - Country:US
Practice Address - Phone:570-271-1995
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS005293L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1675644Medicaid
PA1675644Medicaid
PAR07452Medicare UPIN