Basic Information
| Provider Information | |||||||||
| NPI: | 1326484015 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEADLEY | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | REBEKAH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO, MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 717 S HOUSTON AVE #A | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741279023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183823178 | ||||||||
| FaxNumber: | 9183826789 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 S BLISS AVE | ||||||||
| Address2: | |||||||||
| City: | TAHLEQUAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744642512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184583100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2013 | ||||||||
| LastUpdateDate: | 06/16/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 208600000X | R3534 | AZ | N | Allopathic & Osteopathic Physicians | Surgery | 390200000X | OK | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.