Provider Demographics
NPI:1265702112
Name:DAMON, CHANN (LICSW)
Entity type:Individual
Prefix:
First Name:CHANN
Middle Name:
Last Name:DAMON
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 BAYBERRY DR
Mailing Address - Street 2:
Mailing Address - City:EASTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01027-2751
Mailing Address - Country:US
Mailing Address - Phone:413-527-0902
Mailing Address - Fax:
Practice Address - Street 1:421 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LEEDS
Practice Address - State:MA
Practice Address - Zip Code:01053-9764
Practice Address - Country:US
Practice Address - Phone:413-584-4040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-10
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10310191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical