Provider Demographics
NPI:1063536621
Name:LONG, KRISTA MICHELLE (MSW, LISW, RPT)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:MICHELLE
Last Name:LONG
Suffix:
Gender:F
Credentials:MSW, LISW, RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2065 WOODTRAIL DRIVE
Mailing Address - Street 2:UNIT 14
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014
Mailing Address - Country:US
Mailing Address - Phone:513-829-3139
Mailing Address - Fax:
Practice Address - Street 1:5642 HAMILTON AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45224-3114
Practice Address - Country:US
Practice Address - Phone:513-636-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.101081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical