Provider Demographics
NPI:1962563106
Name:LONG, MARVIN LIONEL JR (ED D)
Entity type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:LIONEL
Last Name:LONG
Suffix:JR
Gender:M
Credentials:ED D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1626 VETERANS BLVD
Mailing Address - Street 2:SUITE E
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-3576
Mailing Address - Country:US
Mailing Address - Phone:478-272-1066
Mailing Address - Fax:478-272-1066
Practice Address - Street 1:1626 VETERANS BLVD
Practice Address - Street 2:SUITE E
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-3576
Practice Address - Country:US
Practice Address - Phone:478-272-1066
Practice Address - Fax:478-272-1066
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA538103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist