Basic Information
| Provider Information | |||||||||
| NPI: | 1639319940 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEADLEY | ||||||||
| FirstName: | KRISTEL | ||||||||
| MiddleName: | DAWNE | ||||||||
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| Credential: | L.P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1021 W OAKLAND AVE | ||||||||
| Address2: | SUITE 207 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376042191 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239155100 | ||||||||
| FaxNumber: | 4239523109 | ||||||||
| Practice Location | |||||||||
| Address1: | 2300 PAVILION DR | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376604622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238575571 | ||||||||
| FaxNumber: | 4238575237 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2009 | ||||||||
| LastUpdateDate: | 02/26/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 2339 | TN | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.