Provider Demographics
NPI:1083040489
Name:LONG, MICHEL LARAYNE (LCSW)
Entity type:Individual
Prefix:
First Name:MICHEL
Middle Name:LARAYNE
Last Name:LONG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MICHEL
Other - Middle Name:LARAYNE
Other - Last Name:BEGUIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5345 WOODLAKE TRCE
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32563-9592
Mailing Address - Country:US
Mailing Address - Phone:417-655-2597
Mailing Address - Fax:
Practice Address - Street 1:113 LIELMANIS AVE
Practice Address - Street 2:
Practice Address - City:HURLBURT FIELD
Practice Address - State:FL
Practice Address - Zip Code:32544-5613
Practice Address - Country:US
Practice Address - Phone:850-461-5651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-18
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS8771104100000X
FLSW137981041C0700X
MO20150400671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200579430BMedicaid