Provider Demographics
NPI:1760960850
Name:LONG, LAUREN CHARLES (MSE, ATC, LAT)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:CHARLES
Last Name:LONG
Suffix:
Gender:F
Credentials:MSE, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5751 CURRAN RD
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:IL
Mailing Address - Zip Code:62670-6772
Mailing Address - Country:US
Mailing Address - Phone:217-899-2368
Mailing Address - Fax:
Practice Address - Street 1:1025 MAINE ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301
Practice Address - Country:US
Practice Address - Phone:217-222-6550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-01
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0039632255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer