Provider Demographics
NPI:1558728485
Name:LONG, MICHAEL A (MA, LMFT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:LONG
Suffix:
Gender:M
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1322
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97709-1322
Mailing Address - Country:US
Mailing Address - Phone:541-213-7755
Mailing Address - Fax:866-497-3686
Practice Address - Street 1:2955 N HWY 97 # 206
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-7559
Practice Address - Country:US
Practice Address - Phone:541-213-7755
Practice Address - Fax:866-497-3686
Is Sole Proprietor?:No
Enumeration Date:2016-01-22
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
ORT1425106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500698687Medicaid