Healthcare Provider Details

I. General information

NPI: 1164435244
Provider Name (Legal Business Name): STANLEY LONG DBA HARBOR LIGHTS PROFESSIONAL CHEMICAL DEPENDENCY SERVIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 07/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3358 MAIN ST
MEXICO NY
13114
US

IV. Provider business mailing address

PO BOX 716 3358 MAIN ST
MEXICO NY
13114
US

V. Phone/Fax

Practice location:
  • Phone: 315-963-0777
  • Fax: 345-963-0611
Mailing address:
  • Phone: 315-963-0777
  • Fax: 345-963-0611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number080211024
License Number StateNY

VIII. Authorized Official

Name: MR. STANLEY E LONG
Title or Position: OWNER
Credential:
Phone: 315-963-0777