MEDICARE: MR. ERNEST E 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	101YA0400X	Addiction (Substance Use Disorder) Counselor		OK

General Provider Information

NPI Number	:	1740576503
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ERNEST E LONG

Provider Business Mailing Address
First Line	:	2701 NE 19TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73111-1911
Country	:	US
Telephone Number	:	405-551-5053
Fax Number	:

Provider Business Practice Location Address
First Line	:	2701 NE 19TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73111-1911
Country	:	US
Telephone Number	:	405-886-9161
Fax Number	:

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

Provider Enumeration Date	:	06/21/2011
Last Update Date	:	06/21/2011

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Directions to “ MR. ERNEST E LONG ” Practice Location

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