Provider Demographics
NPI:1043195712
Name:PENN, DAMON
Entity type:Individual
Prefix:
First Name:DAMON
Middle Name:
Last Name:PENN
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 1:9438 ADELAIDE LANE
Mailing Address - Street 2:IMAGINELIFELLC@AOL.COM
Mailing Address - City:OWINGS MILL
Mailing Address - State:MD
Mailing Address - Zip Code:21117
Mailing Address - Country:US
Mailing Address - Phone:410-458-8427
Mailing Address - Fax:
Practice Address - Street 1:9438 ADELAIDE LANE
Practice Address - Street 2:IMAGINELIFELLC@AOL.COM
Practice Address - City:OWINGS MILL
Practice Address - State:MD
Practice Address - Zip Code:21117
Practice Address - Country:US
Practice Address - Phone:410-458-8427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-11
Last Update Date:2025-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities