Provider Demographics
NPI:1679839021
Name:EASLEY, MYLES LAMONT SR
Entity Type:Individual
Prefix:MR
First Name:MYLES
Middle Name:LAMONT
Last Name:EASLEY
Suffix:SR
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 1:583 SOUTHLAKE BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23236-3096
Mailing Address - Country:US
Mailing Address - Phone:804-594-6142
Mailing Address - Fax:
Practice Address - Street 1:583 SOUTHLAKE BLVD STE B
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23236-3096
Practice Address - Country:US
Practice Address - Phone:804-594-6142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-10
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA174502029Medicaid