Healthcare Provider Details

I. General information

NPI: 1306054671
Provider Name (Legal Business Name): OLEN JADE DODD CRC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2007
Last Update Date: 07/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 RUSTIC HILLS DR
CRAB ORCHARD WV
25827-9658
US

IV. Provider business mailing address

PO BOX 301
BECKLEY WV
25802-0301
US

V. Phone/Fax

Practice location:
  • Phone: 304-253-4537
  • Fax: 304-253-4537
Mailing address:
  • Phone: 304-253-4537
  • Fax: 304-253-4537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: