Basic Information
Provider Information | |||||||||
NPI: | 1598334443 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DAMON | ||||||||
FirstName: | DAVID | ||||||||
MiddleName: | BROCK | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | P-LPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 604 HIGHWAY 80 W STE R | ||||||||
Address2: |   | ||||||||
City: | CLINTON | ||||||||
State: | MS | ||||||||
PostalCode: | 390564108 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7692344979 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 604 HIGHWAY 80 W STE R | ||||||||
Address2: |   | ||||||||
City: | CLINTON | ||||||||
State: | MS | ||||||||
PostalCode: | 390564108 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6014732106 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/23/2021 | ||||||||
LastUpdateDate: | 10/22/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: | 09/22/2021 | ||||||||
NPIReactivationDate: | 10/14/2021 | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/20/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X |   |   | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 171M00000X |   |   | Y |   | Other Service Providers | Case Manager/Care Coordinator |   |
No ID Information.