Provider Demographics
NPI:1396076204
Name:HEADLEY, CHARLES E III
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:E
Last Name:HEADLEY
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 72
Mailing Address - Street 2:456 1ST ST.
Mailing Address - City:VESTABURG
Mailing Address - State:PA
Mailing Address - Zip Code:15368-0072
Mailing Address - Country:US
Mailing Address - Phone:412-999-1924
Mailing Address - Fax:
Practice Address - Street 1:75 HICKLE ST
Practice Address - Street 2:
Practice Address - City:UNIONTOWN
Practice Address - State:PA
Practice Address - Zip Code:15401-4350
Practice Address - Country:US
Practice Address - Phone:724-437-9871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-18
Last Update Date:2010-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI002097225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant