Healthcare Provider Details

I. General information

NPI: 1598334443
Provider Name (Legal Business Name): DAVID BROCK DAMON P-LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2021
Last Update Date: 10/22/2021
Certification Date: 10/20/2021
Deactivation Date: 09/22/2021
Reactivation Date: 10/14/2021

III. Provider practice location address

604 HIGHWAY 80 W STE R
CLINTON MS
39056-4108
US

IV. Provider business mailing address

604 HIGHWAY 80 W STE R
CLINTON MS
39056-4108
US

V. Phone/Fax

Practice location:
  • Phone: 601-473-2106
  • Fax:
Mailing address:
  • Phone: 769-234-4979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: