Healthcare Provider Details

I. General information

NPI: 1407125511
Provider Name (Legal Business Name): STEPHANIE MARIE LONG PH.D., MSCP, ABPP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2011
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13348 JASPER CT
FAIRFAX VA
22033-1405
US

IV. Provider business mailing address

13348 JASPER CT
FAIRFAX VA
22033-1405
US

V. Phone/Fax

Practice location:
  • Phone: 703-568-9476
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number311244
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number810007571
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number04975
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: