Healthcare Provider Details

I. General information

NPI: 1841985066
Provider Name (Legal Business Name): GRANITE STATE COUNSELING AND ASSESSMENT, P.L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2023
Last Update Date: 04/05/2023
Certification Date: 04/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

466 CENTRAL AVE STE 8
DOVER NH
03820-6418
US

IV. Provider business mailing address

466 CENTRAL AVE STE 8
DOVER NH
03820-6418
US

V. Phone/Fax

Practice location:
  • Phone: 207-292-2546
  • Fax:
Mailing address:
  • Phone: 207-292-2546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: DR. RYAN M LONG
Title or Position: PRINCIPAL
Credential: LCMHC
Phone: 207-292-2546