MEDICARE: MARY ELIZABETH EASTON PSY.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist

General Provider Information

NPI Number	:	1932276169
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY ELIZABETH EASTON PSY.D.

Provider Business Mailing Address
First Line	:	1721 SHIVERS RD
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29210-5413
Country	:	US
Telephone Number	:	803-896-8036
Fax Number	:	803-896-7451

Provider Business Practice Location Address
First Line	:	1721 SHIVERS RD
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29210-5413
Country	:	US
Telephone Number	:	803-896-8036
Fax Number	:	803-896-7451

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/30/2006
Last Update Date	:	12/14/2012

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