MEDICARE: GRISELDA LONGS

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	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1538343173
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRISELDA LONGS

Provider Business Mailing Address
First Line	:	5159 LINCOLN AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90042-2345
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1704 W MANCHESTER AVE STE 103
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90047-3056
Country	:	US
Telephone Number	:	323-751-4778
Fax Number	:

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

Provider Enumeration Date	:	12/18/2007
Last Update Date	:	12/18/2007

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