MEDICARE: JOHN LONG JR.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1063836690
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN LONG JR.

Provider Business Mailing Address
First Line	:	3896 SWENSON ST
Second Line	:	APT 1204B
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-7408
Country	:	US
Telephone Number	:	267-251-3899
Fax Number	:

Provider Business Practice Location Address
First Line	:	3896 SWENSON ST
Second Line	:	APT 1204B
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-7408
Country	:	US
Telephone Number	:	267-251-3899
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/18/2014
Last Update Date	:	02/18/2014

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