Basic Information
| Provider Information | |||||||||
| NPI: | 1619091659 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ODYSSEY PROGRAMS, LLC | ||||||||
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| OtherOrganizationName: | ODYSSEY - DAKOTA COUNTY JUVENILE SERVICE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 MAIN STR | ||||||||
| Address2: | #230 | ||||||||
| City: | NEW BRIGHTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6123267600 | ||||||||
| FaxNumber: | 6123267549 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 HIGHWAY 55 | ||||||||
| Address2: | |||||||||
| City: | HASTINGS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514388219 | ||||||||
| FaxNumber: | 6514388252 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2007 | ||||||||
| LastUpdateDate: | 09/16/2008 | ||||||||
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| AuthorizedOfficialLastName: | LINDEMAN | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | ALAN | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR - REVENUE CYCLE MANAGEMENT | ||||||||
| AuthorizedOfficialTelephone: | 6123267566 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MERIDIAN BEHAVIORAL HEALTH | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 1023927 | MN | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 324500000X | 10239271CDT | MN | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.