Provider Demographics
NPI:1003991738
Name:DALE, MILFRED DOUGLAS (PHD)
Entity Type:Individual
Prefix:
First Name:MILFRED
Middle Name:DOUGLAS
Last Name:DALE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 SW 29TH STREET
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66611
Mailing Address - Country:US
Mailing Address - Phone:785-267-0025
Mailing Address - Fax:785-266-6546
Practice Address - Street 1:2201 SW 29TH STREET
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66611
Practice Address - Country:US
Practice Address - Phone:785-267-0025
Practice Address - Fax:785-266-6546
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKS706103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS043057OtherBC/BS
R31053Medicare UPIN
043057Medicare ID - Type Unspecified