Provider Demographics
NPI:1689167199
Name:DODD, DARRYL WAYNE (LMT, NRTP)
Entity Type:Individual
Prefix:MR
First Name:DARRYL
Middle Name:WAYNE
Last Name:DODD
Suffix:
Gender:M
Credentials:LMT, NRTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 TIMBER RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:TIFFIN
Mailing Address - State:IA
Mailing Address - Zip Code:52340-4716
Mailing Address - Country:US
Mailing Address - Phone:319-621-8184
Mailing Address - Fax:
Practice Address - Street 1:2441 JAMES ST STE 5C
Practice Address - Street 2:
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241-1286
Practice Address - Country:US
Practice Address - Phone:319-621-8184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-08
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA079084225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA079084OtherLICENSED MASSAGE THERAPIST