Provider Demographics
NPI:1427520311
Name:LONG, CHAUNCEY MONROE JR
Entity type:Individual
Prefix:
First Name:CHAUNCEY
Middle Name:MONROE
Last Name:LONG
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1839 OLYMPIA CIR
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-5103
Mailing Address - Country:US
Mailing Address - Phone:419-302-1974
Mailing Address - Fax:
Practice Address - Street 1:16 E AUGLAIZE ST
Practice Address - Street 2:
Practice Address - City:WAPAKONETA
Practice Address - State:OH
Practice Address - Zip Code:45895-1577
Practice Address - Country:US
Practice Address - Phone:567-356-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-18
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health