Basic Information
| Provider Information | |||||||||
| NPI: | 1396131629 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLINT ODYSSEY HOUSE, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 529 MARTIN LUTHER KING BLVD | ||||||||
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| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485022002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102387226 | ||||||||
| FaxNumber: | 8102395518 | ||||||||
| Practice Location | |||||||||
| Address1: | 2414 PETIT ST | ||||||||
| Address2: | |||||||||
| City: | PORT HURON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480607446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102387226 | ||||||||
| FaxNumber: | 8102395518 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2015 | ||||||||
| LastUpdateDate: | 10/20/2021 | ||||||||
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| AuthorizedOfficialLastName: | SHEWMAKER | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | MEG | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8102387226 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | LMSW, CAADC, CCDP-D, | ||||||||
| NPICertificationDate: | 10/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | SA0250303 | MI | Y | Agencies | Community/Behavioral Health |
No ID Information.