Provider Demographics
NPI:1417002569
Name:LONG, J ALAN (PHD)
Entity Type:Individual
Prefix:
First Name:J
Middle Name:ALAN
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:PO BOX 1277
Mailing Address - Street 2:18019 DIXIE 1C
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430
Mailing Address - Country:US
Mailing Address - Phone:708-799-2929
Mailing Address - Fax:708-799-2942
Practice Address - Street 1:18019 DIXIE
Practice Address - Street 2:1C
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430
Practice Address - Country:US
Practice Address - Phone:708-799-2929
Practice Address - Fax:708-799-2942
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical