Provider Demographics
NPI:1316498140
Name:LONG, AIXA L (PSYD)
Entity type:Individual
Prefix:DR
First Name:AIXA
Middle Name:L
Last Name:LONG
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9807 PEPPER TREE PLACE
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:34785
Mailing Address - Country:US
Mailing Address - Phone:813-784-7340
Mailing Address - Fax:813-200-1403
Practice Address - Street 1:601 WEBSTER ST
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:FL
Practice Address - Zip Code:34785-3828
Practice Address - Country:US
Practice Address - Phone:813-784-7340
Practice Address - Fax:813-200-1403
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-17
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY9560103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical