Provider Demographics
NPI:1306935804
Name:LONG, BEVERLY JEAN (PSYD)
Entity type:Individual
Prefix:DR
First Name:BEVERLY
Middle Name:JEAN
Last Name:LONG
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:546 WINONA ST E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55107-2425
Mailing Address - Country:US
Mailing Address - Phone:651-253-8438
Mailing Address - Fax:
Practice Address - Street 1:3301 7TH AVE
Practice Address - Street 2:
Practice Address - City:ANOKA
Practice Address - State:MN
Practice Address - Zip Code:55303-4516
Practice Address - Country:US
Practice Address - Phone:763-712-4060
Practice Address - Fax:763-712-4030
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1680103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral