Basic Information
| Provider Information | |||||||||
| NPI: | 1164525978 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ODIORNE | ||||||||
| FirstName: | RAYMOND | ||||||||
| MiddleName: | J | ||||||||
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| Mailing Information | |||||||||
| Address1: | 136 WOODSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067082504 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 56 CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067022103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037551196 | ||||||||
| FaxNumber: | 2035759675 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP1600X | 000278 | CT | Y | Behavioral Health & Social Service Providers | Counselor | Pastoral |
ID Information
| ID | Type | State | Issuer | Description | ANTHEM | 01 | CT | 24000278CT04 | OTHER | COMP CARE | 01 | CT | ODIOR0010 | OTHER |