MEDICARE: MR. GEORGE R HEADLEY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	070453258

General Provider Information

NPI Number	:	1093384919
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GEORGE R HEADLEY

Provider Business Mailing Address
First Line	:	35 QUEENSWAY LN APT 34
Second Line	:
City	:	SPRING GROVE
State	:	VA
Zip	:	23881-7764
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	35 QUEENSWAY LN APT 34
Second Line	:
City	:	SPRING GROVE
State	:	VA
Zip	:	23881-7764
Country	:	US
Telephone Number	:	347-559-8057
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/24/2021
Last Update Date	:	06/24/2021

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