Provider Demographics
NPI:1902350275
Name:LONG, WILLARD TRUMAN JR (MSW LGSW LCSWA)
Entity Type:Individual
Prefix:MR
First Name:WILLARD
Middle Name:TRUMAN
Last Name:LONG
Suffix:JR
Gender:M
Credentials:MSW LGSW LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7410 CHICKADEE CT
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27332-8810
Mailing Address - Country:US
Mailing Address - Phone:910-824-0608
Mailing Address - Fax:910-466-9001
Practice Address - Street 1:410 FERRY ST
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:WV
Practice Address - Zip Code:25136
Practice Address - Country:US
Practice Address - Phone:304-553-6218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-04
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVBP029401601041C0700X
NCP0130721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9262581OtherMEDICARE GROUP
WV9262581OtherMEDICARE GROUP
WV9262581OtherMEDICARE GROUP