MEDICARE: KRISTY LAUREN LONG AMFT

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	103TC0700X	Clinical Psychologist	AMFT132188	CA

General Provider Information

NPI Number	:	1134834468
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTY LAUREN LONG AMFT

Provider Business Mailing Address
First Line	:	621 S SPRING ST APT 209
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90014-3917
Country	:	US
Telephone Number	:	805-749-0014
Fax Number	:

Provider Business Practice Location Address
First Line	:	2801 OCEAN PARK BLVD
Second Line	:	PNB 346
City	:	SANTA MONICA
State	:	CA
Zip	:	90405-2905
Country	:	US
Telephone Number	:	424-229-2122
Fax Number	:

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

Provider Enumeration Date	:	01/20/2023
Last Update Date	:	10/29/2024

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