Provider Demographics
NPI:1396484770
Name:DALTON, SAMUEL BARRY (LPC)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:BARRY
Last Name:DALTON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:738 S 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-6503
Mailing Address - Country:US
Mailing Address - Phone:208-749-3558
Mailing Address - Fax:
Practice Address - Street 1:151 N 3RD AVE STE 202B
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-6368
Practice Address - Country:US
Practice Address - Phone:208-479-7864
Practice Address - Fax:208-656-7344
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-02
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-8901101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health