Healthcare Provider Details

I. General information

NPI: 1801255880
Provider Name (Legal Business Name): CLIO LONG, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2016
Last Update Date: 03/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8101 HINSON FARM RD STE 117
ALEXANDRIA VA
22306-3404
US

IV. Provider business mailing address

8101 HINSON FARM RD STE 117
ALEXANDRIA VA
22306-3404
US

V. Phone/Fax

Practice location:
  • Phone: 703-479-5610
  • Fax:
Mailing address:
  • Phone: 703-479-5610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number0810004025
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number0810004025
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number0810004025
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810004025
License Number StateVA

VIII. Authorized Official

Name: CLIO LONG
Title or Position: OWNER
Credential: PSY.D
Phone: 703-479-5610