MEDICARE: THERESE LONG

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist
2	106H00000X	Marriage & Family Therapist	T1370	OR

General Provider Information

NPI Number	:	1003217456
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESE LONG

Provider Business Mailing Address
First Line	:	14600 NW CORNELL RD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97229-5442
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4300 NE FREMONT ST STE 260
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97213-1100
Country	:	US
Telephone Number	:	503-544-9996
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/04/2014
Last Update Date	:	01/25/2024

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Directions to “ THERESE LONG ” Practice Location

Language	Start Address	Practice Location

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