Healthcare Provider Details

I. General information

NPI: 1346674231
Provider Name (Legal Business Name): KAREN LONG LISW-S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2013
Last Update Date: 10/02/2020
Certification Date: 09/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

88MDG/SGHJ 4881 SUGAR MAPLE DR.
WRIGHT-PATTERSON AFB OH
45433
US

IV. Provider business mailing address

3189 BUGLE BLUFF DR
BELLBROOK OH
45305-8854
US

V. Phone/Fax

Practice location:
  • Phone: 937-929-0982
  • Fax:
Mailing address:
  • Phone: 937-499-3685
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0026986
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: