Provider Demographics
NPI:1942669627
Name:DALTON, BRENDA
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:DALTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:L
Other - Last Name:CARPENTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 MOCKINGBIRD LN
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-2602
Mailing Address - Country:US
Mailing Address - Phone:918-647-7700
Mailing Address - Fax:918-647-2385
Practice Address - Street 1:100 MOCKINGBIRD LN
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-2602
Practice Address - Country:US
Practice Address - Phone:918-647-7700
Practice Address - Fax:918-647-2385
Is Sole Proprietor?:No
Enumeration Date:2016-02-23
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK177587103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool