Provider Demographics
NPI:1659123412
Name:STAMM, DALTON LANE
Entity Type:Individual
Prefix:
First Name:DALTON
Middle Name:LANE
Last Name:STAMM
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:LUNIRA
Other - Middle Name:
Other - Last Name:LANE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:7108 S KANNER HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-7462
Mailing Address - Country:US
Mailing Address - Phone:855-832-6727
Mailing Address - Fax:
Practice Address - Street 1:500 W JOHNSON ST
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604-1347
Practice Address - Country:US
Practice Address - Phone:989-495-3494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-04
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician