Provider Demographics
NPI:1922300722
Name:DALE, LINDA
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:DALE
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:PO BOX 159
Mailing Address - Street 2:
Mailing Address - City:EAGLE LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:33839-0159
Mailing Address - Country:US
Mailing Address - Phone:863-978-8726
Mailing Address - Fax:863-978-1789
Practice Address - Street 1:4305 SHADOW WOOD LN
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-1525
Practice Address - Country:US
Practice Address - Phone:863-978-8726
Practice Address - Fax:863-978-1789
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-30
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL689272896171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL689272896Medicaid
FL689272898Medicaid