Basic Information
| Provider Information | |||||||||
| NPI: | 1871845339 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BATES | ||||||||
| FirstName: | ODESSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 450 MAIN ST | ||||||||
| Address2: | SUITE 450 | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016081812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087522590 | ||||||||
| FaxNumber: | 5087535051 | ||||||||
| Practice Location | |||||||||
| Address1: | 42 SUMMER ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | PITTSFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 012014624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4134420402 | ||||||||
| FaxNumber: | 5087535051 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2012 | ||||||||
| LastUpdateDate: | 10/09/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1308785 | 05 | MA | MEDICAID | 110027991 | 05 | MA | MEDICAID | 1306461 | 05 | MA | MEDICAID | 22220002001 | 01 | MA | BLUE CROSS OF MASS | OTHER | M18684 | 01 | MA | BLUE CROSS BLUE SHEILD | OTHER |