Provider Demographics
NPI:1215745500
Name:LONG, ALYSSA BALTAZAR
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:BALTAZAR
Last Name:LONG
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:IONE
Other - Middle Name:B
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3312 W CHARLESTON BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-1829
Mailing Address - Country:US
Mailing Address - Phone:702-410-7825
Mailing Address - Fax:702-946-0409
Practice Address - Street 1:850 MILL ST STE 100
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-1463
Practice Address - Country:US
Practice Address - Phone:702-410-7825
Practice Address - Fax:702-946-0409
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-19
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator