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General NPI Number Information
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NPI Number | 1215489455
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Entity Type | Organization
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Legal Business Name | DEDE LONG MED, LPC, PC
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Dates
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Enumeration Date | 11/03/2016
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Last Update Date | 11/03/2016
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Provider Practice Location Address
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Address Line | 2545 74TH ST
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City | LUBBOCK
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State | TX
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Zip | 79423-1405
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Country | US
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Telephone | 806-535-1952
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 427
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City | SHALLOWATER
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State | TX
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Zip | 79363-0427
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Country | US
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Telephone | 806-535-1952
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MRS. DEDE STUNTZ LONG
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Credential | MED, LPC
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Telephone | 806-535-1952
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 17725
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License Number State | TX
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