=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619623758
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAUREEN N LONG CDCA II
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2022
-----------------------------------------------------
Last Update Date | 09/21/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 174 MIDWAY BLVD
-----------------------------------------------------
City | ELYRIA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44035-2786
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-723-8997
-----------------------------------------------------
Fax | 440-822-3716
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 174 MIDWAY BLVD
-----------------------------------------------------
City | ELYRIA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44035-2786
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-723-8997
-----------------------------------------------------
Fax | 440-822-3716
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | CDCA.184144
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------