MEDICARE: ATHALIA EASON, LLC

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	101Y00000X	Counselor	0701005618	VA
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	0701005618	VA
3	101YM0800X	Mental Health Counselor	0701005618	VA
4	101YP2500X	Professional Counselor	0701005618	VA

General Provider Information

NPI Number	:	1104255678
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ATHALIA EASON, LLC

Provider Business Mailing Address
First Line	:	5365 DICKERSON RD
Second Line	:
City	:	PARTLOW
State	:	VA
Zip	:	22534-9609
Country	:	US
Telephone Number	:	540-656-3662
Fax Number	:

Provider Business Practice Location Address
First Line	:	1900 BYRD AVE
Second Line	:	SUITE 204
City	:	RICHMOND
State	:	VA
Zip	:	23230-3033
Country	:	US
Telephone Number	:	540-656-3662
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. ATHALIA EASON
Credential	:	LPC, CRC
Telephone Number	:	540-656-3662

Provider Enumeration Date	:	11/05/2013
Last Update Date	:	02/25/2014

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