Provider Demographics
NPI:1306054671
Name:DODD, OLEN JADE (CRC)
Entity type:Individual
Prefix:MR
First Name:OLEN
Middle Name:JADE
Last Name:DODD
Suffix:
Gender:M
Credentials:CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 301
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25802-0301
Mailing Address - Country:US
Mailing Address - Phone:304-253-4537
Mailing Address - Fax:304-253-4537
Practice Address - Street 1:206 RUSTIC HILLS DR
Practice Address - Street 2:
Practice Address - City:CRAB ORCHARD
Practice Address - State:WV
Practice Address - Zip Code:25827-9658
Practice Address - Country:US
Practice Address - Phone:304-253-4537
Practice Address - Fax:304-253-4537
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-19
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV225C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVQRP00000196Medicare UPIN