Provider Demographics
NPI:1578144713
Name:DALTON, BETHANY (LCMHCA, CRC)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:DALTON
Suffix:
Gender:F
Credentials:LCMHCA, CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:677 GRAND CENTRAL STA
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27502-2472
Mailing Address - Country:US
Mailing Address - Phone:919-780-1876
Mailing Address - Fax:919-246-9390
Practice Address - Street 1:315 S SALEM ST STE 222
Practice Address - Street 2:
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502-1848
Practice Address - Country:US
Practice Address - Phone:919-780-1876
Practice Address - Fax:919-246-9390
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA16493101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health