Healthcare Provider Details

I. General information

NPI: 1902228232
Provider Name (Legal Business Name): CHRISTY LONG LCSW, SUDC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2014
Last Update Date: 04/03/2026
Certification Date: 04/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3651 N 100 E STE 350
PROVO UT
84604-4567
US

IV. Provider business mailing address

3651 N 100 E STE 350
PROVO UT
84604-4567
US

V. Phone/Fax

Practice location:
  • Phone: 208-258-5460
  • Fax: 417-794-1186
Mailing address:
  • Phone: 208-258-5460
  • Fax: 417-794-1186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number9045497-3501
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2061976
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: