Healthcare Provider Details

I. General information

NPI: 1922819374
Provider Name (Legal Business Name): DALTON TIMOTHY LYTLE CADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2025
Last Update Date: 01/15/2025
Certification Date: 01/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 6TH ST
MANNING IA
51455-1004
US

IV. Provider business mailing address

1550 6TH ST
MANNING IA
51455-1004
US

V. Phone/Fax

Practice location:
  • Phone: 712-655-8124
  • Fax: 712-655-8241
Mailing address:
  • Phone: 712-655-8124
  • Fax: 712-655-8241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number22147
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: