Provider Demographics
NPI:1992252290
Name:KEITH LONG, LPC, LLC
Entity type:Organization
Organization Name:KEITH LONG, LPC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:303-750-5435
Mailing Address - Street 1:9085 E MISSISSIPPI AVE
Mailing Address - Street 2:APT N107
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80247-4009
Mailing Address - Country:US
Mailing Address - Phone:303-750-5435
Mailing Address - Fax:303-750-5435
Practice Address - Street 1:2323 S TROY ST
Practice Address - Street 2:BLDG. 3, SUITE 108
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-1946
Practice Address - Country:US
Practice Address - Phone:303-750-5435
Practice Address - Fax:303-750-5435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-02
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC.0003080101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1942327895OtherMEDICAID INDIVIDUAL NPI