Provider Demographics
NPI:1295324432
Name:BRONSON, DAMARIS (MED)
Entity type:Individual
Prefix:MRS
First Name:DAMARIS
Middle Name:
Last Name:BRONSON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:MRS
Other - First Name:DAMARIS
Other - Middle Name:
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3504 INDUSTRIAL AVE STE 214
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-7390
Mailing Address - Country:US
Mailing Address - Phone:907-452-4673
Mailing Address - Fax:907-452-1430
Practice Address - Street 1:3504 INDUSTRIAL AVE STE 214
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-7390
Practice Address - Country:US
Practice Address - Phone:907-452-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional