Healthcare Provider Details

I. General information

NPI: 1285759258
Provider Name (Legal Business Name): KAREN MARIE LONG LPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

137 NORTH COTTONWOOD ST.
WOODLAND CA
95695
US

IV. Provider business mailing address

817 TAYLOR ST
WINTERS CA
95694-1508
US

V. Phone/Fax

Practice location:
  • Phone: 530-666-9171
  • Fax:
Mailing address:
  • Phone: 530-666-8630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License NumberPT26008
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: