Provider Demographics
NPI:1871588178
Name:LONG, SONDRA ADELE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:SONDRA
Middle Name:ADELE
Last Name:LONG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:730 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-7020
Mailing Address - Country:US
Mailing Address - Phone:321-242-0525
Mailing Address - Fax:
Practice Address - Street 1:1381 S PATRICK DR
Practice Address - Street 2:BLDG 1370 LIFE SKILLS SUPPORT CENTER 45 MDOS SGOH
Practice Address - City:PATRICK AFB
Practice Address - State:FL
Practice Address - Zip Code:32925-3606
Practice Address - Country:US
Practice Address - Phone:321-494-8234
Practice Address - Fax:321-494-8074
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 44921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical