Provider Demographics
NPI:1710306568
Name:DAMOUS PSYCHOLOGICAL SERVICES PLLC
Entity Type:Organization
Organization Name:DAMOUS PSYCHOLOGICAL SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:DAMOUS
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:304-720-3835
Mailing Address - Street 1:218 D ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25303-3104
Mailing Address - Country:US
Mailing Address - Phone:304-720-3835
Mailing Address - Fax:
Practice Address - Street 1:218 D ST
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25303-3104
Practice Address - Country:US
Practice Address - Phone:304-720-3835
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-09
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV748103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810000195Medicaid
WV3810009212Medicaid