Provider Demographics
NPI:1417619552
Name:EASLEY, ANANDA MARIE (MS, COUI)
Entity Type:Individual
Prefix:
First Name:ANANDA
Middle Name:MARIE
Last Name:EASLEY
Suffix:
Gender:F
Credentials:MS, COUI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2705 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-6601
Mailing Address - Country:US
Mailing Address - Phone:208-346-7500
Mailing Address - Fax:
Practice Address - Street 1:1350 BALDY AVE STE A
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-7104
Practice Address - Country:US
Practice Address - Phone:208-346-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCOUI-8406101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health