Provider Demographics
NPI:1396089538
Name:LONG, MICHAELA SASHEVA
Entity type:Individual
Prefix:
First Name:MICHAELA
Middle Name:SASHEVA
Last Name:LONG
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 1:2362 SOUTH ST APT E
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-4600
Mailing Address - Country:US
Mailing Address - Phone:815-751-7013
Mailing Address - Fax:
Practice Address - Street 1:2362 SOUTH ST APT E
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-4600
Practice Address - Country:US
Practice Address - Phone:815-751-7013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-10
Last Update Date:2012-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.008397101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional