Healthcare Provider Details

I. General information

NPI: 1245695196
Provider Name (Legal Business Name): LORI M LONG LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2015
Last Update Date: 08/03/2023
Certification Date: 08/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 RUSSELL RD NW
ABINGDON VA
24210-2761
US

IV. Provider business mailing address

PO BOX 412
ABINGDON VA
24212-0412
US

V. Phone/Fax

Practice location:
  • Phone: 276-393-5728
  • Fax: 276-628-1112
Mailing address:
  • Phone: 276-393-5728
  • Fax: 276-393-5728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701006000
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: