Individual
MR. JEREMY DE WAYNE LONG
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
LMHC, LPC
Contact information
Practice address
870 HOLLYWOOD BLVD, WEST MELBOURNE, FL 32904-7418
(800) 438-1772
(262) 345-5562
Mailing address
630 TEJON AVE SW, PALM BAY, FL 32908-7437
(321) 482-9492
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
MH 11075
FL
101YP2500X
Professional Counselor
Primary
5617-125
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100057489
—
WI
Enumeration date
05/15/2012
Last updated
08/24/2020
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