Provider Demographics
NPI:1053764480
Name:LONG, EILEEN (LCSW)
Entity type:Individual
Prefix:
First Name:EILEEN
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:EILEEN
Other - Middle Name:
Other - Last Name:ROLD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1001 SOUTHWEST BLVD
Mailing Address - Street 2:STE. F
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-2501
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1001 SOUTHWEST BLVD
Practice Address - Street 2:STE. F
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-2501
Practice Address - Country:US
Practice Address - Phone:573-424-1108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-20
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20130105161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical