Healthcare Provider Details

I. General information

NPI: 1366929242
Provider Name (Legal Business Name): LEAH MICHELE MASSEY-LONGO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LEAH M LONGO

II. Dates (important events)

Enumeration Date: 07/24/2018
Last Update Date: 07/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 THE CITY DR S MANCHESTER OFFICE BUILDING
ORANGE CA
92848
US

IV. Provider business mailing address

1040 W MACARTHUR BLVD APT 20
SANTA ANA CA
92707-4604
US

V. Phone/Fax

Practice location:
  • Phone: 714-935-6363
  • Fax:
Mailing address:
  • Phone: 727-432-0386
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: