Provider Demographics
NPI:1053638791
Name:GUTHERY, DAMON L (BS, MED)
Entity Type:Individual
Prefix:MR
First Name:DAMON
Middle Name:L
Last Name:GUTHERY
Suffix:
Gender:M
Credentials:BS, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 E CARDINAL PL
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130-2517
Mailing Address - Country:US
Mailing Address - Phone:405-615-0706
Mailing Address - Fax:
Practice Address - Street 1:504 E CARDINAL PL
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73130-2517
Practice Address - Country:US
Practice Address - Phone:405-615-0706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-20
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YM0800X, 101YS0200X
OK101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool