MEDICARE: DR. ESTELA (ESTELITA) M LONG PSY. D.

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	PY 6533	FL

General Provider Information

NPI Number	:	1700924826
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ESTELA (ESTELITA) M LONG PSY. D.

Provider Business Mailing Address
First Line	:	934 CYPRESS VILLAGE BLVD
Second Line	:	STE A
City	:	RUSKIN
State	:	FL
Zip	:	33573-6832
Country	:	US
Telephone Number	:	813-634-4700
Fax Number	:	813-634-4703

Provider Business Practice Location Address
First Line	:	4020 SUN CITY CENTER BLVD.
Second Line	:	SUITE 11
City	:	SUN CITY CENTER
State	:	FL
Zip	:	33573-5256
Country	:	US
Telephone Number	:	813-634-4700
Fax Number	:	813-634-4703

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

Provider Enumeration Date	:	02/01/2007
Last Update Date	:	09/17/2016

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