Provider Demographics
NPI:1891390522
Name:DALTON, COLLEEN KELLY
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:KELLY
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 1:15 MIDDLE ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-2718
Mailing Address - Country:US
Mailing Address - Phone:857-207-9982
Mailing Address - Fax:
Practice Address - Street 1:25 STANIFORD ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2503
Practice Address - Country:US
Practice Address - Phone:857-284-4275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA000223891104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker