| Doctor Name: | MS. TELISA LONG |
| NPI Number: | 1285866111 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | |
| License Number: | L52081680690 |
| Business Practice Address: | 413 Indianwood Blvd Park Forest, IL - 604662247 |
| Business Phone Number: | 7083692368 |
| Business Fax Number: | 7087475980 |
| Mailing Address: | 413 Indianwood Blvd, PARK FOREST |
| State: | IL |
| Postal Code: | 604662247 |
| Phone Number: | 7083692368 |
| Fax Number: | 7087475980 |
| NPI Enumeration Date: | 08/11/2009 |
| NPI Last Update Date: | 08/11/2009 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 347C00000X |
| License Number: | L52081680690 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IL |
| Taxonomy Type: | Transportation Services |
| Taxonomy Classification: | Private Vehicle |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An individual paid to provide non-emergency transportation using their privately owned/leased vehicle. |