Healthcare Provider Details

I. General information

NPI: 1841221157
Provider Name (Legal Business Name): JUDITH ROGERS LONG MA, LPC/I
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 01/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1903 GADSDEN ST STE 204
COLUMBIA SC
29201-2352
US

IV. Provider business mailing address

15 WOODPINE CT
COLUMBIA SC
29212-2921
US

V. Phone/Fax

Practice location:
  • Phone: 803-254-9767
  • Fax: 803-254-9740
Mailing address:
  • Phone: 803-732-5572
  • Fax: 508-448-6585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4880
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: