Provider Demographics
NPI:1063608578
Name:GUDELMANN, DALTON (RRW)
Entity type:Individual
Prefix:MR
First Name:DALTON
Middle Name:
Last Name:GUDELMANN
Suffix:
Gender:M
Credentials:RRW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1811 N RAYMOND AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91103-1840
Mailing Address - Country:US
Mailing Address - Phone:626-345-9992
Mailing Address - Fax:626-345-9995
Practice Address - Street 1:1811 N RAYMOND AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91103-1840
Practice Address - Country:US
Practice Address - Phone:626-345-9992
Practice Address - Fax:626-345-9995
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
N/A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)