Provider Demographics
NPI:1730636283
Name:LONGORIA, LILLIAN
Entity Type:Individual
Prefix:
First Name:LILLIAN
Middle Name:
Last Name:LONGORIA
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 1:10046 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-1926
Mailing Address - Country:US
Mailing Address - Phone:773-429-0300
Mailing Address - Fax:773-429-0200
Practice Address - Street 1:10046 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-1926
Practice Address - Country:US
Practice Address - Phone:773-429-0300
Practice Address - Fax:773-429-0200
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL121626-11101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1356385199OtherNATIONAL PROVIDER IDENTIFIER