Provider Demographics
NPI:1528042280
Name:DALTON, JOHN E (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:E
Last Name:DALTON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3420 ILLINOIS ST
Mailing Address - Street 2:REU, BUILDING 1007
Mailing Address - City:GREAT LAKES
Mailing Address - State:IL
Mailing Address - Zip Code:60088-3120
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3420 ILLINOIS ST
Practice Address - Street 2:REU, BUILDING 1007
Practice Address - City:GREAT LAKES
Practice Address - State:IL
Practice Address - Zip Code:60088-3120
Practice Address - Country:US
Practice Address - Phone:847-688-7406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-05
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI830-057103TC0700X
IL103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist