MEDICARE: TIMOTHY D LONG, LMFT

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	101YP2500X	Professional Counselor	LPCC1152	CA
2	106H00000X	Marriage & Family Therapist	47459	CA

General Provider Information

NPI Number	:	1942600606
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIMOTHY D LONG, LMFT

Provider Business Mailing Address
First Line	:	329 N WETHERLY DR
Second Line	:	SUITE 206
City	:	BEVERLY HILLS
State	:	CA
Zip	:	90211-1605
Country	:	US
Telephone Number	:	310-203-1510
Fax Number	:

Provider Business Practice Location Address
First Line	:	329 N WETHERLY DR
Second Line	:	SUITE 206
City	:	BEVERLY HILLS
State	:	CA
Zip	:	90211-1605
Country	:	US
Telephone Number	:	310-203-1510
Fax Number	:

Authorized Official
Title or Position	:	CLINIC DIRECTOR
Name	:	MR. TIMOTHY D LONG
Credential	:	LMFT, LPCC
Telephone Number	:	310-203-1510

Provider Enumeration Date	:	09/01/2014
Last Update Date	:	09/01/2014

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