Individual
DAMON PETERSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.ED, PBSF
Contact information
Practice address
24812 BRICKWOOD MEADOW LN, PETERSBURG, VA 23803-8869
(804) 861-5201
Mailing address
PO BOX 334, PETERSBURG, VA 23804-0334
(804) 861-5201
Taxonomy
Speciality
Code
Description
License number
State
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
Primary
148
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0160289598
—
VA
Enumeration date
04/24/2010
Last updated
04/24/2010
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