Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YM0800X | Mental Health Counselor | 34000540A | IN |
N | 101YP2500X | Professional Counselor | 34000540A | IN |
NPI | 1003354598 |
---|---|
Provider Name | Richard Long |
First Address | Pendleton, IN 46064 |
Second Address | Pendleton, IN 46064-9026 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/02/2017 |
Last Update Date | 06/02/2017 |