Provider Demographics
NPI:1578616991
Name:BLANK, DAMON (LMFT, CGP)
Entity Type:Individual
Prefix:
First Name:DAMON
Middle Name:
Last Name:BLANK
Suffix:
Gender:M
Credentials:LMFT, CGP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 W MILL ST
Mailing Address - Street 2:
Mailing Address - City:MEDFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02052-1554
Mailing Address - Country:US
Mailing Address - Phone:508-359-6631
Mailing Address - Fax:508-359-6631
Practice Address - Street 1:5 W MILL ST
Practice Address - Street 2:
Practice Address - City:MEDFIELD
Practice Address - State:MA
Practice Address - Zip Code:02052-1554
Practice Address - Country:US
Practice Address - Phone:508-359-6631
Practice Address - Fax:508-359-6631
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist