Provider Demographics
NPI:1568500270
Name:HEADLEY, ANGELA MARIE (SLP)
Entity Type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:MARIE
Last Name:HEADLEY
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1226 W OSBORN RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-3618
Mailing Address - Country:US
Mailing Address - Phone:602-707-2007
Mailing Address - Fax:602-707-2040
Practice Address - Street 1:1226 W OSBORN RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-3618
Practice Address - Country:US
Practice Address - Phone:602-707-2007
Practice Address - Fax:602-707-2040
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP1642235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ614463Medicaid