Basic Information
| Provider Information | |||||||||
| NPI: | 1114597572 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLINT ODYSSEY HOUSE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 529 MARTIN LUTHER KING JUNIOR BLVD | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485022002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102385888 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1216 MARTIN LUTHER KING AVE | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485031446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102385888 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2021 | ||||||||
| LastUpdateDate: | 06/29/2021 | ||||||||
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| AuthorizedOfficialLastName: | HARPER-SHELTON | ||||||||
| AuthorizedOfficialFirstName: | ROCHELL | ||||||||
| AuthorizedOfficialMiddleName: | DENELL | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 8102387226 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FLINT ODYSSEY HOUSE, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MSA | ||||||||
| NPICertificationDate: | 06/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.