MEDICARE: DR. KENNETH LAMAR LONG PH.D.

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	103T00000X	Psychologist	PY 8295	FL

General Provider Information

NPI Number	:	1720287253
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH LAMAR LONG PH.D.

Provider Business Mailing Address
First Line	:	1254 OCALA RD
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32304-1548
Country	:	US
Telephone Number	:	850-575-8954
Fax Number	:	850-575-9445

Provider Business Practice Location Address
First Line	:	1254 OCALA RD
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32304-1548
Country	:	US
Telephone Number	:	850-575-8954
Fax Number	:	850-575-9445

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

Provider Enumeration Date	:	07/14/2007
Last Update Date	:	06/09/2011

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