Provider Demographics
NPI:1689970055
Name:DALTON, OTHELLA KAY
Entity Type:Individual
Prefix:
First Name:OTHELLA
Middle Name:KAY
Last Name:DALTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 WOODRIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-5324
Mailing Address - Country:US
Mailing Address - Phone:864-451-3462
Mailing Address - Fax:
Practice Address - Street 1:413B SE MAIN ST
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681-2651
Practice Address - Country:US
Practice Address - Phone:864-688-2430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-02
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6880225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist