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General NPI Number Information
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NPI Number | 1083040489
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Entity Type | Individual
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Provider Name | MICHEL LARAYNE LONG LCSW
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Gender | Female
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Dates
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Enumeration Date | 09/18/2013
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Last Update Date | 05/31/2022
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Provider Practice Location Address
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Address Line | 113 LIELMANIS AVE
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City | HURLBURT FIELD
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State | FL
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Zip | 32544-5613
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Country | US
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Telephone | 850-461-5651
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Fax |
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Provider Business Mailing Address
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Address Line | 5345 WOODLAKE TRCE
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City | GULF BREEZE
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State | FL
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Zip | 32563-9592
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Country | US
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Telephone | 417-655-2597
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 8771
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License Number State | KS
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | SW13798
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 2015040067
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License Number State | MO
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