Provider Demographics
NPI:1194412502
Name:LONG, SKYLAR PAIGE (PLADC)
Entity type:Individual
Prefix:
First Name:SKYLAR
Middle Name:PAIGE
Last Name:LONG
Suffix:
Gender:F
Credentials:PLADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 WENWOOD CT
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-5127
Mailing Address - Country:US
Mailing Address - Phone:712-215-0202
Mailing Address - Fax:
Practice Address - Street 1:2915 GRANT ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68111-3863
Practice Address - Country:US
Practice Address - Phone:402-451-3553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEP-2054101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)