Basic Information
| Provider Information | |||||||||
| NPI: | 1568418176 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRIMMO-LONGE | ||||||||
| FirstName: | OLUFUNKE | ||||||||
| MiddleName: | LOUISE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 781076 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482781076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175284800 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1116 N 16TH ST | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 47904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654236300 | ||||||||
| FaxNumber: | 7654236301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 03/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 01066491A | IN | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 2084P0800X | 01066491A | IN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 200956140 | 05 | IN | MEDICAID | P01634463 | 01 | IN | RAILROAD MEDICARE | OTHER |