Provider Demographics
NPI:1447521356
Name:LONG, SHANE RAYMOND (LMFT)
Entity type:Individual
Prefix:MR
First Name:SHANE
Middle Name:RAYMOND
Last Name:LONG
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 MISSION HOUSE LN
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-2571
Mailing Address - Country:US
Mailing Address - Phone:651-636-5120
Mailing Address - Fax:651-636-5124
Practice Address - Street 1:516 MISSION HOUSE LN
Practice Address - Street 2:
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-2571
Practice Address - Country:US
Practice Address - Phone:651-636-5120
Practice Address - Fax:651-636-5124
Is Sole Proprietor?:No
Enumeration Date:2012-01-24
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2462106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist