Provider Demographics
NPI:1902354160
Name:LONGO, ROBERT
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:LONGO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 CORAL GABLES DR
Mailing Address - Street 2:
Mailing Address - City:LAVALLETTE
Mailing Address - State:NJ
Mailing Address - Zip Code:08735-3019
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:404 CORAL GABLES DR
Practice Address - Street 2:
Practice Address - City:LAVALLETTE
Practice Address - State:NJ
Practice Address - Zip Code:08735-3019
Practice Address - Country:US
Practice Address - Phone:732-814-5875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-16
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00120900101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional