Healthcare Provider Details

I. General information

NPI: 1215455621
Provider Name (Legal Business Name): EMILY HEADLEY DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2017
Last Update Date: 05/02/2024
Certification Date: 05/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 RICKER RD
SALEM IL
62881-4263
US

IV. Provider business mailing address

300 GREEN ST
ODIN IL
62870-1062
US

V. Phone/Fax

Practice location:
  • Phone: 618-548-3194
  • Fax: 618-548-4902
Mailing address:
  • Phone: 618-775-6444
  • Fax: 618-775-6964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: