Provider Demographics
NPI:1346482924
Name:HEASLEY, THOMAS LEE (LMFT)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:LEE
Last Name:HEASLEY
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:MR
Other - First Name:THOMAS
Other - Middle Name:LEE
Other - Last Name:HEASLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:PO BOX 21701
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-0172
Mailing Address - Country:US
Mailing Address - Phone:540-355-8626
Mailing Address - Fax:540-283-0769
Practice Address - Street 1:2727 ELECTRIC RD STE 103
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-3500
Practice Address - Country:US
Practice Address - Phone:540-355-8626
Practice Address - Fax:540-283-0769
Is Sole Proprietor?:No
Enumeration Date:2009-03-30
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701005051101YP2500X
VA0717001182106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1346482924Medicaid