Provider Demographics
NPI:1427839976
Name:LONG, LAURA JANE (PHD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:JANE
Last Name:LONG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:JANE
Other - Last Name:MCCLENAHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:20 WATERTOWN ST UNIT 410
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-2585
Mailing Address - Country:US
Mailing Address - Phone:847-431-2890
Mailing Address - Fax:
Practice Address - Street 1:900 COMMONWEALTH AVE
Practice Address - Street 2:SECOND FLOOR RM 264
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215
Practice Address - Country:US
Practice Address - Phone:617-358-4303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-11
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38466390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program