Healthcare Provider Details

I. General information

NPI: 1912599309
Provider Name (Legal Business Name): CHARLES WILBURN LONG III PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2021
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 GEMINI CIR
BIRMINGHAM AL
35209-5842
US

IV. Provider business mailing address

135 GEMINI CIR
BIRMINGHAM AL
35209-5842
US

V. Phone/Fax

Practice location:
  • Phone: 205-201-0658
  • Fax: 205-293-2270
Mailing address:
  • Phone: 205-201-0658
  • Fax: 205-293-2270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1-141931
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1-141931
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: