Provider Demographics
NPI:1689148173
Name:BARTLEY, DALTON ANDREW
Entity Type:Individual
Prefix:
First Name:DALTON
Middle Name:ANDREW
Last Name:BARTLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 CO RD 1350 N
Mailing Address - Street 2:
Mailing Address - City:CARMI
Mailing Address - State:IL
Mailing Address - Zip Code:62821
Mailing Address - Country:US
Mailing Address - Phone:618-384-1341
Mailing Address - Fax:
Practice Address - Street 1:108 APRIL AVE
Practice Address - Street 2:
Practice Address - City:CARMI
Practice Address - State:IL
Practice Address - Zip Code:62821
Practice Address - Country:US
Practice Address - Phone:618-382-2771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-17
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.012845225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist