=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104228006
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SQUARE ONE FAMILY NETWORKS CORP.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2014
-----------------------------------------------------
Last Update Date | 10/08/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1708 LOCUST AVE STE 201
-----------------------------------------------------
City | FAIRMONT
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26554-1332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-694-7636
-----------------------------------------------------
Fax | 888-977-2130
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1708 LOCUST AVE STE 201
-----------------------------------------------------
City | FAIRMONT
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26554-1332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-694-7636
-----------------------------------------------------
Fax | 888-977-2130
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | JAYME DAWN DODD
-----------------------------------------------------
Credential | LSW
-----------------------------------------------------
Telephone | 304-657-8943
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number | 332608
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number | AP00944042
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------