Provider Demographics
NPI:1932506953
Name:EASON, BRANDON
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:EASON
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 1:1297 PROFESSIONAL DR STE 101B
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-5713
Mailing Address - Country:US
Mailing Address - Phone:912-600-1110
Mailing Address - Fax:
Practice Address - Street 1:1297 PROFESSIONAL DR STE 101B
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-5713
Practice Address - Country:US
Practice Address - Phone:912-600-1110
Practice Address - Fax:888-510-1019
Is Sole Proprietor?:No
Enumeration Date:2014-11-20
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
MAS26882443222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist