Healthcare Provider Details

I. General information

NPI: 1366051989
Provider Name (Legal Business Name): SHILOH SHANE DALTON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2020
Last Update Date: 09/07/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14819 E MISSION AVE
SPOKANE VALLEY WA
99216-1960
US

IV. Provider business mailing address

628 S COWLEY ST
SPOKANE WA
99202-1377
US

V. Phone/Fax

Practice location:
  • Phone: 509-315-9791
  • Fax: 509-474-9612
Mailing address:
  • Phone: 509-624-3227
  • Fax: 509-835-4272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCO61151332
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: