Provider Demographics
NPI:1487141404
Name:PETRO-LONG, CAROL
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:PETRO-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 1:8270 WILLOW OAKS CORPORATE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4511
Mailing Address - Country:US
Mailing Address - Phone:571-423-4034
Mailing Address - Fax:571-423-4037
Practice Address - Street 1:8270 WILLOW OAKS CORPORATE DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4511
Practice Address - Country:US
Practice Address - Phone:571-423-4034
Practice Address - Fax:571-423-4037
Is Sole Proprietor?:No
Enumeration Date:2018-04-16
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904002704104100000X
VAPPS-06059911041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No104100000XBehavioral Health & Social Service ProvidersSocial Worker