Healthcare Provider Details

I. General information

NPI: 1336552520
Provider Name (Legal Business Name): SANSANEE LONGBRAKE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2014
Last Update Date: 07/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 BARTSON RD
FREMONT OH
43420-9672
US

IV. Provider business mailing address

675 BARTSON RD
FREMONT OH
43420-9672
US

V. Phone/Fax

Practice location:
  • Phone: 419-332-5524
  • Fax: 419-332-7581
Mailing address:
  • Phone: 419-332-5524
  • Fax: 419-332-7581

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC1300189
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: