Provider Demographics
NPI:1376015396
Name:LONGLEY, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:LONGLEY
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 1:851 WASHINGTON BLVD APT A2
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-3851
Mailing Address - Country:US
Mailing Address - Phone:708-955-3934
Mailing Address - Fax:
Practice Address - Street 1:851 WASHINGTON BLVD APT A2
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-3851
Practice Address - Country:US
Practice Address - Phone:708-955-3934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-02
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018447-1103TC0700X
IL071.008872103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical