Provider Demographics
NPI:1497153365
Name:DANIELS, DAMON
Entity Type:Individual
Prefix:
First Name:DAMON
Middle Name:
Last Name:DANIELS
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 1:13854 LAKESIDE CIR
Mailing Address - Street 2:SUITE 255
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313-1316
Mailing Address - Country:US
Mailing Address - Phone:517-881-9320
Mailing Address - Fax:
Practice Address - Street 1:13854 LAKESIDE CIR STE 255
Practice Address - Street 2:SUITE 255
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313-1316
Practice Address - Country:US
Practice Address - Phone:517-881-9320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-09
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401014628101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional