Provider Demographics
NPI:1871145540
Name:LONG, KELSEY
Entity type:Individual
Prefix:MS
First Name:KELSEY
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8873 QUIMPER PL
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5620
Mailing Address - Country:US
Mailing Address - Phone:318-686-0012
Mailing Address - Fax:
Practice Address - Street 1:8873 QUIMPER PL
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5620
Practice Address - Country:US
Practice Address - Phone:318-686-0012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-12
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5308101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor