Provider Demographics
NPI:1366051989
Name:DALTON, SHILOH SHANE
Entity type:Individual
Prefix:
First Name:SHILOH
Middle Name:SHANE
Last Name:DALTON
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 1:628 S COWLEY ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-1377
Mailing Address - Country:US
Mailing Address - Phone:509-624-3227
Mailing Address - Fax:509-835-4272
Practice Address - Street 1:14819 E MISSION AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-1960
Practice Address - Country:US
Practice Address - Phone:509-315-9791
Practice Address - Fax:509-474-9612
Is Sole Proprietor?:No
Enumeration Date:2020-07-29
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61151332101YA0400X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACO61151332OtherSUDP LICENSE