Healthcare Provider Details

I. General information

NPI: 1558843946
Provider Name (Legal Business Name): TAVY LONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2018
Last Update Date: 03/14/2024
Certification Date: 03/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3604-B FAIR OAKS BLVD. SUITE 200
SACRAMENTO CA
95864
US

IV. Provider business mailing address

PO BOX 33568
SAN DIEGO CA
92163-3568
US

V. Phone/Fax

Practice location:
  • Phone: 855-223-7123
  • Fax:
Mailing address:
  • Phone: 855-223-7123
  • Fax: 619-374-7134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-24-70948
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-18-57415
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: