Provider Demographics
NPI:1508471327
Name:DALY, JOHN EDWARD (R1404710920)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:EDWARD
Last Name:DALY
Suffix:
Gender:M
Credentials:R1404710920
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1152 SONOMA AVE
Mailing Address - Street 2:
Mailing Address - City:SEASIDE
Mailing Address - State:CA
Mailing Address - Zip Code:93955-5218
Mailing Address - Country:US
Mailing Address - Phone:831-899-2436
Mailing Address - Fax:831-899-7405
Practice Address - Street 1:1152 SONOMA AVE
Practice Address - Street 2:
Practice Address - City:SEASIDE
Practice Address - State:CA
Practice Address - Zip Code:93955-5218
Practice Address - Country:US
Practice Address - Phone:831-899-2436
Practice Address - Fax:831-899-7405
Is Sole Proprietor?:No
Enumeration Date:2020-09-09
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1404710920101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)