Provider Demographics
NPI:1194120865
Name:LONG, SHARLENE
Entity type:Individual
Prefix:
First Name:SHARLENE
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3551 E BONANZA RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89110-0055
Mailing Address - Country:US
Mailing Address - Phone:918-359-9410
Mailing Address - Fax:866-518-0781
Practice Address - Street 1:3551 E BONANZA RD
Practice Address - Street 2:SUITE 101
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89110-0055
Practice Address - Country:US
Practice Address - Phone:918-359-9410
Practice Address - Fax:866-518-0781
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-23
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health