Healthcare Provider Details

I. General information

NPI: 1750128021
Provider Name (Legal Business Name): ABBIGAIL RENAE LONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2024
Last Update Date: 07/12/2024
Certification Date: 07/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 MANSFIELD AVE
SHELBY OH
44875-1832
US

IV. Provider business mailing address

1216 PIN OAK DR APT B
WILLARD OH
44890-9442
US

V. Phone/Fax

Practice location:
  • Phone: 567-292-9211
  • Fax:
Mailing address:
  • Phone: 419-689-2275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: