Healthcare Provider Details

I. General information

NPI: 1083788871
Provider Name (Legal Business Name): AMY LYNN EASLEY L.C.S.W.-C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 01/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 W CHESAPEAKE AVE SUITE 509
TOWSON MD
21204-4345
US

IV. Provider business mailing address

123 HERITAGE LN
SYKESVILLE MD
21784-9418
US

V. Phone/Fax

Practice location:
  • Phone: 443-519-5752
  • Fax:
Mailing address:
  • Phone: 410-971-1371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number09465
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier405288900
Identifier TypeMEDICAID
Identifier StateMD
Identifier Issuer
# 2
Identifier808601000
Identifier TypeMEDICAID
Identifier StateMD
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: