MEDICARE: MR. DEREK DALTON LAC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	639	MT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0000076391	OTHER	MT	BLUE CROSS BLUE SHIELD
2	76555	OTHER	MT	CHIP
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386775971
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DEREK DALTON LAC

Provider Business Mailing Address
First Line	:	1312 NORTH MERIDIAN
Second Line	:
City	:	KALISPELL
State	:	MT
Zip	:	59904
Country	:	US
Telephone Number	:	406-756-6453
Fax Number	:	406-756-8546

Provider Business Practice Location Address
First Line	:	1312 NORTH MERIDIAN
Second Line	:
City	:	KALISPELL
State	:	MT
Zip	:	59904-0115
Country	:	US
Telephone Number	:	406-756-6453
Fax Number	:	406-756-8546

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

Provider Enumeration Date	:	03/08/2007
Last Update Date	:	07/08/2007

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