Basic Information
| Provider Information | |||||||||
| NPI: | 1316317027 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FLINT ODYSSEY HOUSE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3499 S LINDEN RD | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485073022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8108208121 | ||||||||
| FaxNumber: | 8108208335 | ||||||||
| Practice Location | |||||||||
| Address1: | 529 M L KING AVE | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485022002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102327919 | ||||||||
| FaxNumber: | 8102327913 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2015 | ||||||||
| LastUpdateDate: | 10/07/2015 | ||||||||
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| AuthorizedOfficialLastName: | SHEWMAKER | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8105168313 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | LMSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | SA0250387 | MI | Y | Agencies | Community/Behavioral Health |
No ID Information.