Provider Demographics
NPI:1730101569
Name:TODD, JOHN BRUCE (PHD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:BRUCE
Last Name:TODD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4009
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25364-4009
Mailing Address - Country:US
Mailing Address - Phone:304-348-1288
Mailing Address - Fax:304-348-1262
Practice Address - Street 1:1418A MACCORKLE AVE SW
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25303
Practice Address - Country:US
Practice Address - Phone:304-348-1288
Practice Address - Fax:304-348-1262
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV710103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9205058000Medicaid
TOCP21877Medicare ID - Type Unspecified