MEDICARE: MYISHA LONG LCSW

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	1041C0700X	Clinical Social Worker	41518	TX
2	104100000X	Social Worker	41518	TX

General Provider Information

NPI Number	:	1982794145
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MYISHA LONG LCSW

Provider Business Mailing Address
First Line	:	1036 BADGER RUN
Second Line	:
City	:	LANCASTER
State	:	TX
Zip	:	75134-4618
Country	:	US
Telephone Number	:	972-228-4384
Fax Number	:	972-228-4384

Provider Business Practice Location Address
First Line	:	1036 BADGER RUN
Second Line	:
City	:	LANCASTER
State	:	TX
Zip	:	75134-4618
Country	:	US
Telephone Number	:	972-228-4384
Fax Number	:	972-228-4384

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

Provider Enumeration Date	:	10/16/2006
Last Update Date	:	09/21/2011

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Directions to “ MYISHA LONG LCSW” Practice Location

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