Basic Information
| Provider Information | |||||||||
| NPI: | 1942242037 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DALTON | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12012 WICKCHESTER LN | ||||||||
| Address2: | SUITE 550 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770791229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8324482800 | ||||||||
| FaxNumber: | 8324482801 | ||||||||
| Practice Location | |||||||||
| Address1: | 12012 WICKCHESTER LN | ||||||||
| Address2: | SUITE 550 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770791229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8324482800 | ||||||||
| FaxNumber: | 8324482801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 03/10/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 25358 | TX | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 041075502 | 05 | TX | MEDICAID | 83149P | 01 | TX | BCBS | OTHER | 83153P | 01 | TX | BCBS | OTHER | 680014099 | 01 | TX | RAILROAD | OTHER | 041075503 | 05 | TX | MEDICAID |