Healthcare Provider Details

I. General information

NPI: 1265876940
Provider Name (Legal Business Name): ANNETTE ELISE LONG M.ED.S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2013
Last Update Date: 04/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4303 CENTRAL AVE.PIKE
KNOXVILLE TN
37912
US

IV. Provider business mailing address

4303 CENTRAL AVENUE PIKE
KNOXVILLE TN
37912-4310
US

V. Phone/Fax

Practice location:
  • Phone: 865-247-7045
  • Fax: 865-249-8458
Mailing address:
  • Phone: 865-247-7045
  • Fax: 865-249-8458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: