Healthcare Provider Details

I. General information

NPI: 1619981008
Provider Name (Legal Business Name): LEE K LONG LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2410 HWY 65 N DEETA COUNSELING ASSOCIATES INC
MCGEHEE AR
71654
US

IV. Provider business mailing address

PO BOX 34
SAINT CHARLES AR
72140-0034
US

V. Phone/Fax

Practice location:
  • Phone: 870-222-3107
  • Fax:
Mailing address:
  • Phone: 870-282-3113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1672C
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: