=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265224265
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMY LONG MS, LSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2025
-----------------------------------------------------
Last Update Date | 08/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1709 JUMER DR STE A
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61704-0914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 872-239-8292
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 621 ORLANDO AVE APT 101
-----------------------------------------------------
City | NORMAL
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61761-6019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-585-4812
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 150.107177
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------