Provider Demographics
NPI:1306125372
Name:DALTON, REGINALD A (MBA, BS)
Entity type:Individual
Prefix:
First Name:REGINALD
Middle Name:A
Last Name:DALTON
Suffix:
Gender:M
Credentials:MBA, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1075 GAULT DR
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198-6427
Mailing Address - Country:US
Mailing Address - Phone:734-547-7814
Mailing Address - Fax:
Practice Address - Street 1:1075 GAULT DR
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48198-6427
Practice Address - Country:US
Practice Address - Phone:734-547-7814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-09
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health