Provider Demographics
NPI:1073782884
Name:DALTON, CHARLES BRADY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:BRADY
Last Name:DALTON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3118 E MARYLAND AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-2377
Mailing Address - Country:US
Mailing Address - Phone:602-909-7539
Mailing Address - Fax:
Practice Address - Street 1:3118 E MARYLAND AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-2377
Practice Address - Country:US
Practice Address - Phone:602-909-7539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-26
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3660103TC0700X, 103TA0400X, 103TA0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1073782884Medicaid