Provider Demographics
NPI:1811242803
Name:LONG, GRIFFIN (LISW)
Entity type:Individual
Prefix:MR
First Name:GRIFFIN
Middle Name:
Last Name:LONG
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 265
Mailing Address - Street 2:
Mailing Address - City:MOUNT EATON
Mailing Address - State:OH
Mailing Address - Zip Code:44659-0265
Mailing Address - Country:US
Mailing Address - Phone:330-359-6100
Mailing Address - Fax:
Practice Address - Street 1:15550 DURSTINE RD
Practice Address - Street 2:
Practice Address - City:DUNDEE
Practice Address - State:OH
Practice Address - Zip Code:44624-9428
Practice Address - Country:US
Practice Address - Phone:330-359-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-17
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OHI.16002571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator