Provider Demographics
NPI:1043571938
Name:DALTON, LESLIE W JR
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:W
Last Name:DALTON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:CANYON
Mailing Address - State:TX
Mailing Address - Zip Code:79015-5519
Mailing Address - Country:US
Mailing Address - Phone:806-656-0788
Mailing Address - Fax:
Practice Address - Street 1:2501 4TH AVE
Practice Address - Street 2:
Practice Address - City:CANYON
Practice Address - State:TX
Practice Address - Zip Code:79016-0001
Practice Address - Country:US
Practice Address - Phone:806-651-5108
Practice Address - Fax:806-651-5105
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-06
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX104700235Z00000X, 231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist