Provider Demographics
NPI:1902981079
Name:LONGIN, EVAN MARK (EDD)
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:MARK
Last Name:LONGIN
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MA
Mailing Address - Zip Code:01970-4721
Mailing Address - Country:US
Mailing Address - Phone:978-744-5006
Mailing Address - Fax:978-744-9799
Practice Address - Street 1:204 LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970-4721
Practice Address - Country:US
Practice Address - Phone:978-744-5006
Practice Address - Fax:978-744-9799
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1693103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
W01792Medicare UPIN
MAW01792Medicare ID - Type Unspecified
MA718139Medicare UPIN