MEDICARE: LEA LONG LCSW-PIP

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	104100000X	Social Worker	5128	SD

General Provider Information

NPI Number	:	1891451662
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEA LONG LCSW-PIP

Provider Business Mailing Address
First Line	:	4400 W 69TH ST
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57108-8170
Country	:	US
Telephone Number	:	605-322-4008
Fax Number	:

Provider Business Practice Location Address
First Line	:	4400 W 69TH ST STE 100
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57108-8172
Country	:	US
Telephone Number	:	605-322-4008
Fax Number	:	605-322-4009

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

Provider Enumeration Date	:	11/16/2021
Last Update Date	:	11/16/2021

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