Provider Demographics
NPI:1518012590
Name:LONG, LAURA LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:LYNN
Last Name:LONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:122 S MICHIGAN AVE
Mailing Address - Street 2:SUITE 1406
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60603-6191
Mailing Address - Country:US
Mailing Address - Phone:312-882-9119
Mailing Address - Fax:312-663-3796
Practice Address - Street 1:122 S MICHIGAN AVE
Practice Address - Street 2:SUITE 1406
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60603-6191
Practice Address - Country:US
Practice Address - Phone:312-882-9119
Practice Address - Fax:312-663-3796
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL0361147932084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK53376OtherMEDICARE PTAN