Healthcare Provider Details

I. General information

NPI: 1336206572
Provider Name (Legal Business Name): MARIE ANN LONG LPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7200 BANCROFT AVE EASTMONT TOWN CENTER BLDG. B SUITE 133
OAKLAND CA
94605-2403
US

IV. Provider business mailing address

9909 BANCROFT AVE
OAKLAND CA
94603-2815
US

V. Phone/Fax

Practice location:
  • Phone: 510-553-8500
  • Fax: 510-553-8550
Mailing address:
  • Phone: 510-553-8500
  • Fax: 510-553-8550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number22054
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: