Provider Demographics
NPI:1912164864
Name:LONG, CLIFFORD LEE (BS)
Entity type:Individual
Prefix:MR
First Name:CLIFFORD
Middle Name:LEE
Last Name:LONG
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4131 PALM AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38128-6320
Mailing Address - Country:US
Mailing Address - Phone:901-377-2303
Mailing Address - Fax:
Practice Address - Street 1:3810 WINCHESTER RD
Practice Address - Street 2:SOUTHEAST MENTAL HEALTH CENTER
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38118-6045
Practice Address - Country:US
Practice Address - Phone:901-369-1480
Practice Address - Fax:901-369-1452
Is Sole Proprietor?:No
Enumeration Date:2008-05-19
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator