Healthcare Provider Details

I. General information

NPI: 1063498640
Provider Name (Legal Business Name): RHONDA DALLAS
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 80 BOX 20887
APO AP
96367
JP

IV. Provider business mailing address

PSC 80 BOX 20887
APO AP
96367
JP

V. Phone/Fax

Practice location:
  • Phone: 01181614
  • Fax: 0433
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number280
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: