Healthcare Provider Details

I. General information

NPI: 1306578000
Provider Name (Legal Business Name): KELLI ROS LONG PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2022
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 JOHNS HOPKINS DR
GREENVILLE NC
27834-2056
US

IV. Provider business mailing address

905 JOHNS HOPKINS DR
GREENVILLE NC
27834-2056
US

V. Phone/Fax

Practice location:
  • Phone: 252-744-1406
  • Fax: 252-744-2419
Mailing address:
  • Phone: 252-744-1406
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number6623
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6623
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: