Basic Information
| Provider Information | |||||||||
| NPI: | 1285965418 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DALTON | ||||||||
| FirstName: | LAURIE | ||||||||
| MiddleName: | LIN | ||||||||
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| Credential: | B.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1775 CHESTNUT AVE | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908131674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5625998444 | ||||||||
| FaxNumber: | 5625916134 | ||||||||
| Practice Location | |||||||||
| Address1: | 3125 E 7TH ST | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908044932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5629875722 | ||||||||
| FaxNumber: | 5624386891 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2010 | ||||||||
| LastUpdateDate: | 02/15/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 330355130 | 05 | CA | MEDICAID |