Basic Information
| Provider Information | |||||||||
| NPI: | 1588065569 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ODYSSEY HOUSE LOUISIANA, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1125 NORTH TONTI STREET | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048219211 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1125 N TONTI ST | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701193549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048219211 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2014 | ||||||||
| LastUpdateDate: | 02/17/2016 | ||||||||
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| AuthorizedOfficialLastName: | CARLSON | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5048219211 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MFT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 050 | LA | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.