Basic Information
| Provider Information | |||||||||
| NPI: | 1538334503 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANH | ||||||||
| FirstName: | LONG | ||||||||
| MiddleName: | GIA | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LCSW, MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9691 | ||||||||
| Address2: | |||||||||
| City: | LOWELL | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018539691 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1115 W CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023017501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9784536800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2008 | ||||||||
| LastUpdateDate: | 08/10/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 23682 | CA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 215938 | MA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.