Provider Demographics
NPI:1326484015
Name:HEADLEY, SHANNON (DO, LPC)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:HEADLEY
Suffix:
Gender:F
Credentials:DO, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 E BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:SAND SPRINGS
Mailing Address - State:OK
Mailing Address - Zip Code:74063-7965
Mailing Address - Country:US
Mailing Address - Phone:918-245-5565
Mailing Address - Fax:
Practice Address - Street 1:401 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:SAND SPRINGS
Practice Address - State:OK
Practice Address - Zip Code:74063-7965
Practice Address - Country:US
Practice Address - Phone:918-245-5565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-21
Last Update Date:2024-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS21177208D00000X
OK5650101YM0800X
OK390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health