Provider Demographics
NPI:1558735464
Name:LONG, KATHLYN (CADC)
Entity Type:Individual
Prefix:
First Name:KATHLYN
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 RIVERVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:FOX LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60020-1473
Mailing Address - Country:US
Mailing Address - Phone:815-527-1448
Mailing Address - Fax:
Practice Address - Street 1:34 RIVERVIEW AVE
Practice Address - Street 2:
Practice Address - City:FOX LAKE
Practice Address - State:IL
Practice Address - Zip Code:60020-1473
Practice Address - Country:US
Practice Address - Phone:815-527-1448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-17
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker