Provider Demographics
NPI:1487408928
Name:WINTER, DAMON JONATHAN
Entity type:Individual
Prefix:
First Name:DAMON
Middle Name:JONATHAN
Last Name:WINTER
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 1:2910 W MARCONI AVE UNIT 201
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85053-4046
Mailing Address - Country:US
Mailing Address - Phone:602-559-7164
Mailing Address - Fax:
Practice Address - Street 1:7155 W CAMPO BELLO DR STE C120
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8594
Practice Address - Country:US
Practice Address - Phone:602-363-0629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-12
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-22654101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health