Provider Demographics
NPI:1487497418
Name:HEADLEY, CONRAD I (MSC, LAC)
Entity type:Individual
Prefix:MR
First Name:CONRAD
Middle Name:I
Last Name:HEADLEY
Suffix:
Gender:M
Credentials:MSC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12417 MOUNTAIN LAUREL DR.
Mailing Address - Street 2:
Mailing Address - City:EAST STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18302-8634
Mailing Address - Country:US
Mailing Address - Phone:570-269-6255
Mailing Address - Fax:
Practice Address - Street 1:12417 MOUNTAIN LAUREL DR.
Practice Address - Street 2:
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18302-8634
Practice Address - Country:US
Practice Address - Phone:570-421-2260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-17
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAK001431171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist