=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003331968
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DALTON J BOLEY LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2017
-----------------------------------------------------
Last Update Date | 12/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1800 BEVERLY AVE
-----------------------------------------------------
City | MUSCLE SHOALS
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35661-3255
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-701-5651
-----------------------------------------------------
Fax | 256-429-9411
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 600 SUN TEMPLE DR
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35758-8643
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-288-3333
-----------------------------------------------------
Fax | 256-288-3334
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 4823C
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------