Provider Demographics
NPI:1104263284
Name:LONGO, MICHELENE M (LADC)
Entity type:Individual
Prefix:
First Name:MICHELENE
Middle Name:M
Last Name:LONGO
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:991 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-2274
Mailing Address - Country:US
Mailing Address - Phone:860-528-3238
Mailing Address - Fax:860-528-3267
Practice Address - Street 1:991 MAIN ST
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108-2274
Practice Address - Country:US
Practice Address - Phone:860-528-3238
Practice Address - Fax:860-528-3267
Is Sole Proprietor?:No
Enumeration Date:2013-05-29
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000834101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)