Provider Demographics
NPI:1265224265
Name:LONG, AMY (MS, LSW)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:MS, LSW
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
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 1:1709 JUMER DR STE A
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-0914
Practice Address - Country:US
Practice Address - Phone:312-553-0403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-19
Last Update Date:2025-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.107177104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker