Provider Demographics
NPI:1386095552
Name:LONG, WILMA (LPC)
Entity type:Individual
Prefix:
First Name:WILMA
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:W.
Other - Middle Name:BETH
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:3003 N CENTRAL AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2902
Mailing Address - Country:US
Mailing Address - Phone:602-685-6132
Mailing Address - Fax:602-302-7925
Practice Address - Street 1:4909 E MCDOWELL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-7735
Practice Address - Country:US
Practice Address - Phone:602-685-6000
Practice Address - Fax:602-275-1355
Is Sole Proprietor?:No
Enumeration Date:2016-06-28
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-11061101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional