Provider Demographics
NPI:1487433835
Name:DAWALT, PHILLIP ROBERT JR (CADAC II ADDICTIONS)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:ROBERT
Last Name:DAWALT
Suffix:JR
Gender:M
Credentials:CADAC II ADDICTIONS
Other - Prefix:
Other - First Name:ROB
Other - Middle Name:
Other - Last Name:DAWALT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CADAC II
Mailing Address - Street 1:207 WESTMINSTER WAY
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46013-4462
Mailing Address - Country:US
Mailing Address - Phone:765-374-9399
Mailing Address - Fax:
Practice Address - Street 1:1418 JACKSON ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46016-1619
Practice Address - Country:US
Practice Address - Phone:765-506-7329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN25049101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)