Provider Demographics
NPI:1508321217
Name:ISOM, DAMON KEITH (RBT)
Entity Type:Individual
Prefix:MR
First Name:DAMON
Middle Name:KEITH
Last Name:ISOM
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9428 MORRISDALE WAY
Mailing Address - Street 2:
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23116-2321
Mailing Address - Country:US
Mailing Address - Phone:804-334-4512
Mailing Address - Fax:
Practice Address - Street 1:4100 PRICE CLUB BLVD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-3379
Practice Address - Country:US
Practice Address - Phone:804-674-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-06
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-18-55288106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician