Provider Demographics
NPI:1083212005
Name:LONG, AMANDA MICHELE (PHD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:MICHELE
Last Name:LONG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22939 MILLARD AVE
Mailing Address - Street 2:
Mailing Address - City:RICHTON PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60471-2534
Mailing Address - Country:US
Mailing Address - Phone:708-724-8044
Mailing Address - Fax:
Practice Address - Street 1:20280 GOVERNORS HWY STE 105
Practice Address - Street 2:
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1068
Practice Address - Country:US
Practice Address - Phone:312-248-3481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-12
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071010371103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical