MEDICARE: MALINDA MARIE 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	101Y00000X	Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	9574	OTHER	CA	UBH

General Provider Information

NPI Number	:	1952412959
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MALINDA MARIE LONG

Provider Business Mailing Address
First Line	:	1471 GROVE AVE APT 33
Second Line	:
City	:	IMPERIAL BEACH
State	:	CA
Zip	:	91932-3655
Country	:	US
Telephone Number	:	619-573-7822
Fax Number	:

Provider Business Practice Location Address
First Line	:	1840 WILSON AVE STE C
Second Line	:
City	:	NATIONAL CITY
State	:	CA
Zip	:	91950-5515
Country	:	US
Telephone Number	:	619-477-0795
Fax Number	:

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

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	07/08/2007

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Directions to “ MALINDA MARIE LONG ” Practice Location

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