Provider Demographics
NPI:1053174201
Name:LONG, IMANI
Entity type:Individual
Prefix:
First Name:IMANI
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13462 FIRESTONE ST
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92344-9416
Mailing Address - Country:US
Mailing Address - Phone:442-433-7185
Mailing Address - Fax:
Practice Address - Street 1:4141 S NOGALES ST
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91792-3056
Practice Address - Country:US
Practice Address - Phone:833-831-8946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-31
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool