Provider Demographics
NPI:1710658356
Name:DALTON, NICHOLE (MS)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:DALTON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4323 CHIPMUNK DR
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34653-6434
Mailing Address - Country:US
Mailing Address - Phone:443-404-8271
Mailing Address - Fax:
Practice Address - Street 1:8002 KING HELIE BLVD
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34653-1435
Practice Address - Country:US
Practice Address - Phone:443-404-8271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-23
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH22174101YM0800X
FLIMH20862101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health