Basic Information
| Provider Information | |||||||||
| NPI: | 1790297133 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEADLEY | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 641 REBER RD | ||||||||
| Address2: | |||||||||
| City: | MIFFLINBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178446935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704125070 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 241 BROAD ST | ||||||||
| Address2: | |||||||||
| City: | MONTOURSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 177542283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704337060 | ||||||||
| FaxNumber: | 5705677184 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2017 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | PC000652 | PA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.