Provider Demographics
NPI:1508290990
Name:EASLEY, DEREK PAUL (LCSW)
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:PAUL
Last Name:EASLEY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10580 LIGON MILL RD
Mailing Address - Street 2:210
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-4575
Mailing Address - Country:US
Mailing Address - Phone:919-263-9592
Mailing Address - Fax:919-263-9670
Practice Address - Street 1:10580 LIGON MILL RD
Practice Address - Street 2:210
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-4575
Practice Address - Country:US
Practice Address - Phone:919-263-9592
Practice Address - Fax:919-263-9670
Is Sole Proprietor?:No
Enumeration Date:2013-08-21
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0096241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical