Provider Demographics
NPI:1073263349
Name:HUCKABY, DALTON WAYNE JR (AMFT)
Entity Type:Individual
Prefix:MR
First Name:DALTON
Middle Name:WAYNE
Last Name:HUCKABY
Suffix:JR
Gender:M
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 FAIR OAKS AVE # 22
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-3311
Mailing Address - Country:US
Mailing Address - Phone:415-264-6107
Mailing Address - Fax:
Practice Address - Street 1:3191 CASITAS AVE STE 157
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90039-2470
Practice Address - Country:US
Practice Address - Phone:323-627-7020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-28
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT131903106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty