Provider Demographics
NPI:1740779917
Name:EASLEY, TINA MARIE (CPC RC SUDPT)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:EASLEY
Suffix:
Gender:F
Credentials:CPC RC SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3017 SAUK DR
Mailing Address - Street 2:
Mailing Address - City:CAMANO ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98282-8232
Mailing Address - Country:US
Mailing Address - Phone:425-387-3634
Mailing Address - Fax:
Practice Address - Street 1:1227 2ND ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-4906
Practice Address - Country:US
Practice Address - Phone:360-651-2366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-03
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60938049101YA0400X
WA61283707101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)