Healthcare Provider Details

I. General information

NPI: 1154247864
Provider Name (Legal Business Name): PATRICIA W. HEADMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2026
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2534 FARRAGUT DR
SPRINGFIELD IL
62704-1457
US

IV. Provider business mailing address

118 WHITE BIRCH RD
SPRINGFIELD IL
62712-8756
US

V. Phone/Fax

Practice location:
  • Phone: 217-494-7547
  • Fax:
Mailing address:
  • Phone: 121-749-4754
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178.032795
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: