Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 102L00000X | Psychologist | 3660 | AZ |
N | 103T00000X | Psychologist | 3660 | AZ |
N | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | 3660 | AZ |
N | 103TA0700X | Adult Development & Aging Psychologist | 3660 | AZ |
Y | 103G00000X | Clinical Psychologist | 3660 | AZ |
Y | 103TC0700X | Clinical Psychologist | 3660 | AZ |
NPI | 1073782884 |
---|---|
Provider Name | Dr. Charles Brady Dalton |
First Address | Phoenix, AZ 85016-2377 |
Second Address | Phoenix, AZ 85016-2377 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/02/2008 |
Last Update Date | 29/04/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1073782884 | (05) | AZ |