Provider Demographics
NPI:1265224265
Name:LONG, AMY DAWN (MS, LSW)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:DAWN
Last Name:LONG
Suffix:
Gender:F
Credentials:MS, LSW
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:DAWN
Other - Last Name:STEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:621 ORLANDO AVE APT 101
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-6019
Mailing Address - Country:US
Mailing Address - Phone:765-585-4812
Mailing Address - Fax:
Practice Address - Street 1:10 S RIVERSIDE PLZ STE 875
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60606-3717
Practice Address - Country:US
Practice Address - Phone:833-427-2264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-19
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.107177104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker