| Doctor Name: | DAMON PETERSON |
| NPI Number: | 1194042515 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | M.ED, PBSF |
| License Number: | 148 |
| Business Practice Address: | 24812 Brickwood Meadow Ln Petersburg, VA - 238038869 |
| Business Phone Number: | 8048615201 |
| Business Fax Number: | |
| Mailing Address: | Po Box 334, PETERSBURG |
| State: | VA |
| Postal Code: | 238040334 |
| Phone Number: | 8048615201 |
| Fax Number: | |
| NPI Enumeration Date: | 04/24/2010 |
| NPI Last Update Date: | 04/24/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 320900000X |
| License Number: | 148 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | VA |
| Taxonomy Type: | Residential Treatment Facilities |
| Taxonomy Classification: | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A home-like residential facility providing habilitation, support and monitoring services to individuals diagnosed with mental retardation and/or developmental disabilities. |