=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134500713
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAUNIQUE EASON LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2015
-----------------------------------------------------
Last Update Date | 08/10/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 FORT LN
-----------------------------------------------------
City | PORTSMOUTH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23704-2221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-391-5928
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3505 CHIMNEY HILL CT APT 101
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23462-7046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-539-7754
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 72-082207
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 0904011098
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------