Healthcare Provider Details

I. General information

NPI: 1144498882
Provider Name (Legal Business Name): SUZANNE C EASLEY CLT, CNMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2008
Last Update Date: 02/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

327 DAHLONEGA ST STE A902
CUMMING GA
30040-2492
US

IV. Provider business mailing address

1620 GREYSTONE PL
CUMMING GA
30040-5133
US

V. Phone/Fax

Practice location:
  • Phone: 404-218-7004
  • Fax: 770-844-5929
Mailing address:
  • Phone: 770-844-9873
  • Fax: 770-844-5929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License NumberMT004367
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: