Provider Demographics
NPI:1134834468
Name:LONG, KRISTY LAUREN (AMFT)
Entity type:Individual
Prefix:
First Name:KRISTY
Middle Name:LAUREN
Last Name:LONG
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 S SPRING ST APT 209
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90014-3917
Mailing Address - Country:US
Mailing Address - Phone:805-749-0014
Mailing Address - Fax:
Practice Address - Street 1:2801 OCEAN PARK BLVD
Practice Address - Street 2:PNB 346
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-2905
Practice Address - Country:US
Practice Address - Phone:424-229-2122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-20
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT132188103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical