Healthcare Provider Details

I. General information

NPI: 1073782884
Provider Name (Legal Business Name): CHARLES BRADY DALTON PSY.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2008
Last Update Date: 04/29/2021
Certification Date: 04/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3118 E MARYLAND AVE
PHOENIX AZ
85016-2377
US

IV. Provider business mailing address

3118 E MARYLAND AVE
PHOENIX AZ
85016-2377
US

V. Phone/Fax

Practice location:
  • Phone: 602-909-7539
  • Fax:
Mailing address:
  • Phone: 602-909-7539
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3660
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number3660
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number3660
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3660
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: