Provider Demographics
NPI:1407027360
Name:HEADY, PAMELA (MT)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:HEADY
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5133 MAIN STREET
Mailing Address - Street 2:#2
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515
Mailing Address - Country:US
Mailing Address - Phone:815-404-4733
Mailing Address - Fax:630-771-1030
Practice Address - Street 1:303 QUADRANGLE DR
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-3409
Practice Address - Country:US
Practice Address - Phone:630-771-1070
Practice Address - Fax:630-771-1030
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-19
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2252100000XOtherMASSAGE THERAPY