Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP1600X | Pastoral Counselor |
NPI | 1336701127 |
---|---|
Provider Name | Raymond B. Long |
First Address | Winslow, AZ 86047-7072 |
Second Address | Dilkon, AZ 86047 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/07/2019 |
Last Update Date | 02/07/2019 |