Provider Demographics
NPI:1275810244
Name:DAMOTH, MICHAEL (LCAS, LPC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:DAMOTH
Suffix:
Gender:M
Credentials:LCAS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5268 BLUE RIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:BLUE RIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:24064-1833
Mailing Address - Country:US
Mailing Address - Phone:252-473-6518
Mailing Address - Fax:
Practice Address - Street 1:NEW SUMMIT ACADEMY
Practice Address - Street 2:BARRIO FAITIMA
Practice Address - City:ATENAS
Practice Address - State:ALAJUELA
Practice Address - Zip Code:20501
Practice Address - Country:CR
Practice Address - Phone:800-609-9496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-04
Last Update Date:2019-11-13
Deactivation Date:2019-08-28
Deactivation Code:
Reactivation Date:2019-11-13
Provider Licenses
StateLicense IDTaxonomies
NC9143101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health