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General NPI Number Information
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NPI Number | 1194042515
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Entity Type | Individual
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Provider Name | DAMON PETERSON M.ED, PBSF
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Gender | Male
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Dates
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Enumeration Date | 04/24/2010
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Last Update Date | 04/24/2010
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Provider Practice Location Address
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Address Line | 24812 BRICKWOOD MEADOW LN
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City | PETERSBURG
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State | VA
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Zip | 23803-8869
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Country | US
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Telephone | 804-861-5201
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 334
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City | PETERSBURG
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State | VA
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Zip | 23804-0334
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Country | US
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Telephone | 804-861-5201
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number | 148
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License Number State | VA
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