MEDICARE: DR. CHARLES BRADY DALTON PSY.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	3660	AZ
2	103TA0400X	Addiction (Substance Use Disorder) Psychologist	3660	AZ
3	103TA0700X	Adult Development & Aging Psychologist	3660	AZ
4	103T00000X	Psychologist	3660	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073782884
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES BRADY DALTON PSY.D

Provider Business Mailing Address
First Line	:	3118 E MARYLAND AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85016-2377
Country	:	US
Telephone Number	:	602-909-7539
Fax Number	:

Provider Business Practice Location Address
First Line	:	3118 E MARYLAND AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85016-2377
Country	:	US
Telephone Number	:	602-909-7539
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/26/2008
Last Update Date	:	04/29/2021

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