Healthcare Provider Details

I. General information

NPI: 1275808883
Provider Name (Legal Business Name): KRISTEN L LONG LPC, CACII
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTEN L SOLIZ

II. Dates (important events)

Enumeration Date: 03/14/2012
Last Update Date: 12/12/2022
Certification Date: 12/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

84 ACOMA BLVD N STE 104
LAKE HAVASU CITY AZ
86403-6096
US

IV. Provider business mailing address

84 ACOMA BLVD N STE 104
LAKE HAVASU CITY AZ
86403-6096
US

V. Phone/Fax

Practice location:
  • Phone: 928-733-5101
  • Fax: 970-249-2955
Mailing address:
  • Phone: 928-733-5101
  • Fax: 970-249-2955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-16476
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: