Provider Demographics
NPI:1376087668
Name:EASLEY, WESLEY
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:
Last Name:EASLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:843 CHARDONNAY CIR
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-7408
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 PETALUMA BLVD S
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-5545
Practice Address - Country:US
Practice Address - Phone:707-765-8488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-06
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA102869106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist