Provider Demographics
NPI:1912357450
Name:BRANDON, DALTON
Entity Type:Individual
Prefix:
First Name:DALTON
Middle Name:
Last Name:BRANDON
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:PO BOX 881
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820
Mailing Address - Country:US
Mailing Address - Phone:580-559-2347
Mailing Address - Fax:580-559-2357
Practice Address - Street 1:517 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-9501
Practice Address - Country:US
Practice Address - Phone:580-559-2347
Practice Address - Fax:580-559-2357
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-15
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker