Basic Information
| Provider Information | |||||||||
| NPI: | 1700863479 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LONGLETT | ||||||||
| FirstName: | SHIRLEY | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | LCPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19639 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627949639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175457578 | ||||||||
| FaxNumber: | 2175451884 | ||||||||
| Practice Location | |||||||||
| Address1: | 612 N 11TH ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | QUINCY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 623012662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172249484 | ||||||||
| FaxNumber: | 2172247950 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | IL | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.