Provider Demographics
NPI:1063986008
Name:KNIGHT-LONG, LOUISE (LSW)
Entity type:Individual
Prefix:MS
First Name:LOUISE
Middle Name:
Last Name:KNIGHT-LONG
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 FORK STREET
Mailing Address - Street 2:SUITE 13080, THIRD FLOOR
Mailing Address - City:TOBYHANNA
Mailing Address - State:PA
Mailing Address - Zip Code:18344
Mailing Address - Country:US
Mailing Address - Phone:570-580-1115
Mailing Address - Fax:570-580-1120
Practice Address - Street 1:4 FORK STREET
Practice Address - Street 2:SUITE 13080, THIRD FLOOR
Practice Address - City:TOBYHANNA
Practice Address - State:PA
Practice Address - Zip Code:18344
Practice Address - Country:US
Practice Address - Phone:570-580-1115
Practice Address - Fax:570-580-1120
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-13
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA136797101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1497229421OtherMINDBRIDGE