Provider Demographics
NPI:1558603134
Name:HEADLEY, REBECCA E (LCSW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:E
Last Name:HEADLEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 W HAYS ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-5511
Mailing Address - Country:US
Mailing Address - Phone:208-381-6995
Mailing Address - Fax:
Practice Address - Street 1:610 W HAYS ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-5511
Practice Address - Country:US
Practice Address - Phone:208-381-6995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-21
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-32694104100000X
IDLCSW-386161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker