Healthcare Provider Details

I. General information

NPI: 1710622089
Provider Name (Legal Business Name): CHRYSTINE MARIE LONGLEY LCSW. LMSW, LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2022
Last Update Date: 12/06/2024
Certification Date: 12/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 N 4TH ST
BROOKLYN NY
11249-3296
US

IV. Provider business mailing address

134 N 4TH ST
BROOKLYN NY
11249-3296
US

V. Phone/Fax

Practice location:
  • Phone: 646-450-7748
  • Fax:
Mailing address:
  • Phone: 646-450-7748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number3396
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number221902
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLICSW1121089
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: