Provider Demographics
NPI:1679708358
Name:HEADLEY, DEREK (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:HEADLEY
Suffix:
Gender:M
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2704 NE 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:WILTON MANORS
Mailing Address - State:FL
Mailing Address - Zip Code:33334-2654
Mailing Address - Country:US
Mailing Address - Phone:954-218-2184
Mailing Address - Fax:
Practice Address - Street 1:2704 NE 8TH AVE
Practice Address - Street 2:
Practice Address - City:WILTON MANORS
Practice Address - State:FL
Practice Address - Zip Code:33334
Practice Address - Country:US
Practice Address - Phone:954-218-2184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-24
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10739235Z00000X
WV1789235Z00000X
ID2910235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist