Healthcare Provider Details

I. General information

NPI: 1598789406
Provider Name (Legal Business Name): ANGELA NICOLE LONG LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 03/24/2025
Certification Date: 03/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16776 BERNARDO CENTER DR STE 203
SAN DIEGO CA
92128-2559
US

IV. Provider business mailing address

#1088 11160 RANCHO CARMEL DRIVE SUITE 106
SAN DIEGO CA
92128
US

V. Phone/Fax

Practice location:
  • Phone: 858-519-5153
  • Fax:
Mailing address:
  • Phone: 425-518-3763
  • Fax: 800-878-8263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC39384
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: