Healthcare Provider Details

I. General information

NPI: 1356915326
Provider Name (Legal Business Name): ELIZABETH LONG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2021
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5439 BURKHARDT RD
DAYTON OH
45431-2111
US

IV. Provider business mailing address

928 CROYDON CT
VANDALIA OH
45377-1615
US

V. Phone/Fax

Practice location:
  • Phone: 937-791-1440
  • Fax:
Mailing address:
  • Phone: 937-367-2516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC2204215
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberC2103225-TRNE
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: