Basic Information
| Provider Information | |||||||||
| NPI: | 1508290990 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EASLEY | ||||||||
| FirstName: | DEREK | ||||||||
| MiddleName: | PAUL | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10580 LIGON MILL RD | ||||||||
| Address2: | 210 | ||||||||
| City: | WAKE FOREST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275874575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192639592 | ||||||||
| FaxNumber: | 9192639670 | ||||||||
| Practice Location | |||||||||
| Address1: | 10580 LIGON MILL RD | ||||||||
| Address2: | 210 | ||||||||
| City: | WAKE FOREST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275874575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192639592 | ||||||||
| FaxNumber: | 9192639670 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2013 | ||||||||
| LastUpdateDate: | 11/20/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C009624 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.