Provider Demographics
NPI:1710199062
Name:LONG, J. FREDERICK (PHD)
Entity Type:Individual
Prefix:
First Name:J.
Middle Name:FREDERICK
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 1:1525 E 53RD ST
Mailing Address - Street 2:SUITE #421
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-4557
Mailing Address - Country:US
Mailing Address - Phone:773-752-8166
Mailing Address - Fax:
Practice Address - Street 1:1525 E 53RD ST
Practice Address - Street 2:SUITE #421
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-4557
Practice Address - Country:US
Practice Address - Phone:773-752-8166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral