Provider Demographics
NPI:1437672193
Name:DALTON, GREGORY C (LPC, CADCIII, MDIV)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:C
Last Name:DALTON
Suffix:
Gender:M
Credentials:LPC, CADCIII, MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19500 SE STARK ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-5757
Mailing Address - Country:US
Mailing Address - Phone:503-674-4712
Mailing Address - Fax:
Practice Address - Street 1:19500 SE STARK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-5757
Practice Address - Country:US
Practice Address - Phone:503-669-5051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-24
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR14-08-19101YA0400X
ORC3592101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)