Provider Demographics
NPI:1720346372
Name:LONG, KATHLEEN ELLEN (MS CCC-SLP/L)
Entity Type:Individual
Prefix:MISS
First Name:KATHLEEN
Middle Name:ELLEN
Last Name:LONG
Suffix:
Gender:F
Credentials:MS CCC-SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:11142 S CAMPBELL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60655-1316
Mailing Address - Country:US
Mailing Address - Phone:773-239-8089
Mailing Address - Fax:
Practice Address - Street 1:11142 S CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60655-1316
Practice Address - Country:US
Practice Address - Phone:773-239-8089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-01
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.000279235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist