Provider Demographics
NPI:1366648149
Name:LONG, RICHARD (PHD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:LONG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E HILLCREST DR
Mailing Address - Street 2:SUITE 100A
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-2480
Mailing Address - Country:US
Mailing Address - Phone:815-761-2686
Mailing Address - Fax:
Practice Address - Street 1:400 E HILLCREST DR
Practice Address - Street 2:SUITE 100A
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-2480
Practice Address - Country:US
Practice Address - Phone:815-761-2686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical