Provider Demographics
NPI:1609495282
Name:LONG, AJASHA MAXINE (PHD)
Entity type:Individual
Prefix:
First Name:AJASHA
Middle Name:MAXINE
Last Name:LONG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 METROHEALTH DR
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44109-1900
Mailing Address - Country:US
Mailing Address - Phone:314-780-8699
Mailing Address - Fax:
Practice Address - Street 1:14540 OLD SAINT AUGUSTINE RD STE 2591
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-7420
Practice Address - Country:US
Practice Address - Phone:904-376-3800
Practice Address - Fax:904-390-7405
Is Sole Proprietor?:No
Enumeration Date:2020-04-13
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHP.08309103TC1900X
FLPY12271103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling