Provider Demographics
NPI:1700105368
Name:EASLEY, SAMUEL P (LMT)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:P
Last Name:EASLEY
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2314 MIDTOWN TER APT 1133
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32839-4530
Mailing Address - Country:US
Mailing Address - Phone:407-463-6552
Mailing Address - Fax:
Practice Address - Street 1:2314 MIDTOWN TER APT 1133
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32839-4530
Practice Address - Country:US
Practice Address - Phone:407-463-6552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-21
Last Update Date:2010-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA30459225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist