Healthcare Provider Details

I. General information

NPI: 1326098724
Provider Name (Legal Business Name): MICHAEL D LONG PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 05/20/2021
Certification Date: 05/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1270 BELMONT AVE
SCHENECTADY NY
12308-2104
US

IV. Provider business mailing address

PO BOX 14890
ALBANY NY
12212-4890
US

V. Phone/Fax

Practice location:
  • Phone: 518-282-4522
  • Fax:
Mailing address:
  • Phone: 518-525-5634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number011560-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: