Provider Demographics
NPI:1790297133
Name:HEADLEY, DOUGLAS EDWARD (LPC)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:EDWARD
Last Name:HEADLEY
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:641 REBER RD
Mailing Address - Street 2:
Mailing Address - City:MIFFLINBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17844-6935
Mailing Address - Country:US
Mailing Address - Phone:570-412-5070
Mailing Address - Fax:
Practice Address - Street 1:241 BROAD ST
Practice Address - Street 2:
Practice Address - City:MONTOURSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17754-2283
Practice Address - Country:US
Practice Address - Phone:570-433-7060
Practice Address - Fax:570-567-7184
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-25
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC000652101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional