Provider Demographics
NPI:1659859882
Name:DAMON, ROCHESTER COOPER JR
Entity Type:Individual
Prefix:MR
First Name:ROCHESTER
Middle Name:COOPER
Last Name:DAMON
Suffix:JR
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 1:423 CORONA ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-2816
Mailing Address - Country:US
Mailing Address - Phone:336-624-0160
Mailing Address - Fax:
Practice Address - Street 1:1321 ASHLEYBROOK LN
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2918
Practice Address - Country:US
Practice Address - Phone:336-727-3257
Practice Address - Fax:336-727-3258
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-31
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA14107101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty