Healthcare Provider Details

I. General information

NPI: 1104228006
Provider Name (Legal Business Name): SQUARE ONE FAMILY NETWORKS CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2014
Last Update Date: 10/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1708 LOCUST AVE STE 201
FAIRMONT WV
26554-1332
US

IV. Provider business mailing address

1708 LOCUST AVE STE 201
FAIRMONT WV
26554-1332
US

V. Phone/Fax

Practice location:
  • Phone: 304-694-7636
  • Fax: 888-977-2130
Mailing address:
  • Phone: 304-694-7636
  • Fax: 888-977-2130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License NumberAP00944042
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number332608
License Number StateWV

VIII. Authorized Official

Name: JAYME DAWN DODD
Title or Position: OWNER, EXECUTIVE DIRECTOR
Credential: LSW
Phone: 304-657-8943