Healthcare Provider Details

I. General information

NPI: 1023491362
Provider Name (Legal Business Name): PATRICIA ANTOS LONG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2015
Last Update Date: 06/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 COMMERCIAL ST SUITE 330
WORCESTER MA
01608-1726
US

IV. Provider business mailing address

250 COMMERCIAL ST SUITE 330
WORCESTER MA
01608-1726
US

V. Phone/Fax

Practice location:
  • Phone: 508-752-4665
  • Fax: 508-752-0947
Mailing address:
  • Phone: 508-752-4665
  • Fax: 508-752-0947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberRN136685
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: