Provider Demographics
NPI:1356849772
Name:LONG, BRANDIE
Entity Type:Individual
Prefix:
First Name:BRANDIE
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BRANDIE
Other - Middle Name:
Other - Last Name:BOND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2625 BUTTERFIELD RD STE 301N
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1266
Mailing Address - Country:US
Mailing Address - Phone:630-468-1824
Mailing Address - Fax:
Practice Address - Street 1:4125 N SHERIDAN RD STE 14
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-7181
Practice Address - Country:US
Practice Address - Phone:630-468-1824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038012626111N00000X
IL038.012626111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1001001001OtherDONT HAVE