Basic Information
| Provider Information | |||||||||
| NPI: | 1245729045 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ODYSSEY HOUSE LOUISIANA, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | OHL DETOX | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1125 N TONTI ST | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701193549 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4730 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701251226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048219211 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2018 | ||||||||
| LastUpdateDate: | 03/25/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOSWORTH | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | BRIGGS | ||||||||
| AuthorizedOfficialTitleorPosition: | PROGRAM DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5048219211 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ODYSSEY HOUSE LOUISIANA, INC | ||||||||
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| NPICertificationDate: | 03/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.