Healthcare Provider Details

I. General information

NPI: 1295416717
Provider Name (Legal Business Name): PHOEBE EDGERTON LONG PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2023
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5225 WISCONSIN AVE NW STE 400
WASHINGTON DC
20015-2055
US

IV. Provider business mailing address

5225 WISCONSIN AVE NW STE 400
WASHINGTON DC
20015-2055
US

V. Phone/Fax

Practice location:
  • Phone: 202-363-1010
  • Fax:
Mailing address:
  • Phone: 202-363-1010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number0810008528
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY200001635
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: