Healthcare Provider Details

I. General information

NPI: 1053174201
Provider Name (Legal Business Name): IMANI LONG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2024
Last Update Date: 01/31/2024
Certification Date: 01/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4141 S NOGALES ST
WEST COVINA CA
91792-3056
US

IV. Provider business mailing address

13462 FIRESTONE ST
HESPERIA CA
92344-9416
US

V. Phone/Fax

Practice location:
  • Phone: 833-831-8946
  • Fax:
Mailing address:
  • Phone: 442-433-7185
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: