Provider Demographics
NPI:1013311133
Name:SQUARE ONE FAMILY NETWORKS CORP
Entity Type:Organization
Organization Name:SQUARE ONE FAMILY NETWORKS CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAYME
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:DODD
Authorized Official - Suffix:
Authorized Official - Credentials:LSW
Authorized Official - Phone:304-694-7636
Mailing Address - Street 1:1708 LOCUST AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-1332
Mailing Address - Country:US
Mailing Address - Phone:304-694-7636
Mailing Address - Fax:888-977-2130
Practice Address - Street 1:1708 LOCUST AVE STE 201
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-1332
Practice Address - Country:US
Practice Address - Phone:304-694-7636
Practice Address - Fax:888-977-2130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-17
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAP00944042251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management