=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710708052
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTA LONG M.ED., LPC-ASSOCIATE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2024
-----------------------------------------------------
Last Update Date | 10/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 114 CENTER AVE STE 203
-----------------------------------------------------
City | BROWNWOOD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76801-3172
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 325-532-8522
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 701 FM 2126
-----------------------------------------------------
City | EARLY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76802-3908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-413-7681
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 95971
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------