Healthcare Provider Details

I. General information

NPI: 1336829282
Provider Name (Legal Business Name): REAGAN GRACE LONG LCMHC-A
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2023
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 HAY ST
FAYETTEVILLE NC
28305-5312
US

IV. Provider business mailing address

1532 BAINBRIDGE RD
STEDMAN NC
28391-8922
US

V. Phone/Fax

Practice location:
  • Phone: 910-860-7008
  • Fax:
Mailing address:
  • Phone: 910-860-7008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA23419
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: