Basic Information
| Provider Information | |||||||||
| NPI: | 1881810950 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LONG | ||||||||
| FirstName: | COREY | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 70 WAREHAM LAKE SHORE DR | ||||||||
| Address2: | |||||||||
| City: | EAST WAREHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 025381429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5082919946 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 543 NORTH ST | ||||||||
| Address2: | |||||||||
| City: | NEW BEDFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027402766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089845566 | ||||||||
| FaxNumber: | 5089945527 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 1028753 | MA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | PO7323 | 01 | MA | BLUE CROSS BLUE SHIELD | OTHER |