Provider Demographics
NPI:1871288993
Name:LONG, KATRINA SHEREE
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:SHEREE
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATRINA
Other - Middle Name:SHEREE
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCADC
Mailing Address - Street 1:2363 FOXRIDGE CT APT 811
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-4125
Mailing Address - Country:US
Mailing Address - Phone:270-938-2762
Mailing Address - Fax:
Practice Address - Street 1:2349 RUSSELLVILLE RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-3986
Practice Address - Country:US
Practice Address - Phone:270-282-8280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-05
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY281024101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)