Provider Demographics
NPI:1275045452
Name:PERRY, DAMEON DECAVEN
Entity Type:Individual
Prefix:
First Name:DAMEON
Middle Name:DECAVEN
Last Name:PERRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2810 FREDDIE ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-4216
Mailing Address - Country:US
Mailing Address - Phone:318-606-5335
Mailing Address - Fax:318-606-5671
Practice Address - Street 1:106 E KINGS HWY STE 101
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104
Practice Address - Country:US
Practice Address - Phone:318-606-5335
Practice Address - Fax:318-606-5671
Is Sole Proprietor?:No
Enumeration Date:2017-10-28
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
LA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA821613802OtherMENTAL HEALTH