Provider Demographics
NPI:1194452151
Name:BODIFORD, DALTON PAIGE
Entity type:Individual
Prefix:
First Name:DALTON
Middle Name:PAIGE
Last Name:BODIFORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 W 23RD ST BLDG E40
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-3936
Mailing Address - Country:US
Mailing Address - Phone:850-381-9624
Mailing Address - Fax:
Practice Address - Street 1:700 W 23RD ST BLDG E40
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-3936
Practice Address - Country:US
Practice Address - Phone:850-381-9624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-01
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker