Provider Demographics
NPI:1780202051
Name:SHEPHERD, DAMON WYATT
Entity Type:Individual
Prefix:
First Name:DAMON
Middle Name:WYATT
Last Name:SHEPHERD
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 1:751 BETHESDA RD STE 100
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-3300
Mailing Address - Country:US
Mailing Address - Phone:336-774-1113
Mailing Address - Fax:
Practice Address - Street 1:751 BETHESDA RD STE 100
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3300
Practice Address - Country:US
Practice Address - Phone:336-774-1113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-13
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1267231HA2400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231HA2400XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology Practitioner