Provider Demographics
NPI:1699133892
Name:EASOM, VICTORIA (MA, LPC)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:EASOM
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5421 RIVER BLUFF PKWY
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29420-7135
Mailing Address - Country:US
Mailing Address - Phone:843-300-0440
Mailing Address - Fax:
Practice Address - Street 1:5421 RIVER BLUFF PKWY
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29420-7135
Practice Address - Country:US
Practice Address - Phone:843-300-0440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-02
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6770101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional