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General NPI Number Information
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NPI Number | 1285415059
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Entity Type | Individual
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Provider Name | ELLEN MARIE LONG LCSW, CDP
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Gender | Female
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Dates
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Enumeration Date | 10/09/2023
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Last Update Date | 01/10/2025
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Provider Practice Location Address
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Address Line | 302 FALLS OF VENICE CIR
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City | VENICE
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State | FL
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Zip | 34292-3979
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Country | US
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Telephone | 904-607-0160
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Fax |
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Provider Business Mailing Address
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Address Line | 302 FALLS OF VENICE CIR
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City | VENICE
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State | FL
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Zip | 34292-3979
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Country | US
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Telephone | 904-607-0160
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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 | ISW18102
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License Number State | FL
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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 | 24099
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License Number State | FL
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