Provider Demographics
NPI:1285866111
Name:LONG, TELISA
Entity Type:Individual
Prefix:MS
First Name:TELISA
Middle Name:
Last Name: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 1:413 INDIANWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:PARK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60466-2247
Mailing Address - Country:US
Mailing Address - Phone:708-369-2368
Mailing Address - Fax:708-747-5980
Practice Address - Street 1:413 INDIANWOOD BLVD
Practice Address - Street 2:
Practice Address - City:PARK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60466-2247
Practice Address - Country:US
Practice Address - Phone:708-369-2368
Practice Address - Fax:708-747-5980
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-11
Last Update Date:2009-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILL52081680690347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle