Healthcare Provider Details

I. General information

NPI: 1205685096
Provider Name (Legal Business Name): KATHYA HEADLEY MHC-LP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2024
Last Update Date: 05/15/2024
Certification Date: 05/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2369 2ND AVE
NEW YORK NY
10035-3108
US

IV. Provider business mailing address

2369 2ND AVE
NEW YORK NY
10035-3108
US

V. Phone/Fax

Practice location:
  • Phone: 212-876-2300
  • Fax: 212-369-8209
Mailing address:
  • Phone: 212-876-2300
  • Fax: 212-369-8209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number18-P118162-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: