Provider Demographics
NPI:1508643818
Name:THE HEADSHOP, PLLC
Entity Type:Organization
Organization Name:THE HEADSHOP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, CLINICAL DIRECTOR, THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MARDREY
Authorized Official - Middle Name:ALICIA
Authorized Official - Last Name:WADE KILES
Authorized Official - Suffix:
Authorized Official - Credentials:LPC- MHSP
Authorized Official - Phone:901-870-8682
Mailing Address - Street 1:1788 CHESHUNT LN
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-3507
Mailing Address - Country:US
Mailing Address - Phone:901-870-8682
Mailing Address - Fax:901-424-9078
Practice Address - Street 1:5104 STAGE RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38134-3164
Practice Address - Country:US
Practice Address - Phone:901-870-8682
Practice Address - Fax:901-424-9078
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE HEADSHOP, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty