=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598789406
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANGELA NICOLE LONG LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2006
-----------------------------------------------------
Last Update Date | 03/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16776 BERNARDO CENTER DR STE 203
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92128-2559
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-519-5153
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | #1088 11160 RANCHO CARMEL DRIVE SUITE 106
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-518-3763
-----------------------------------------------------
Fax | 800-878-8263
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFC39384
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------