Provider Demographics
NPI:1275074429
Name:DALTON, COLLEEN
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:DALTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 POWDER HILL DR
Mailing Address - Street 2:
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:32 POWDER HILL DR
Practice Address - Street 2:
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184
Practice Address - Country:US
Practice Address - Phone:617-543-2478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-20
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1-16-23535103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst