Provider Demographics
NPI:1396109401
Name:LONG, RODNEY JR (MSSA, LISW-S)
Entity type:Individual
Prefix:MR
First Name:RODNEY
Middle Name:
Last Name:LONG
Suffix:JR
Gender:M
Credentials:MSSA, LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:162 NORTHEAST AVE.
Mailing Address - Street 2:PO BOX 342
Mailing Address - City:TALLMADGE
Mailing Address - State:OH
Mailing Address - Zip Code:44278
Mailing Address - Country:US
Mailing Address - Phone:330-958-4038
Mailing Address - Fax:
Practice Address - Street 1:10 W STREETSBORO ST STE 105
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:OH
Practice Address - Zip Code:44236-2851
Practice Address - Country:US
Practice Address - Phone:330-510-1388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-06
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1302449104100000X, 1041C0700X
OHI.2102842-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1396109401OtherNPI
OH027471Medicaid