Basic Information
| Provider Information | |||||||||
| NPI: | 1982128393 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLINT ODYSSEY HOUSE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 529 M L KING AVE | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485022002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102387226 | ||||||||
| FaxNumber: | 8102395518 | ||||||||
| Practice Location | |||||||||
| Address1: | 718 OAK ST | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485032614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102387226 | ||||||||
| FaxNumber: | 8102395518 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2017 | ||||||||
| LastUpdateDate: | 10/20/2021 | ||||||||
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| AuthorizedOfficialLastName: | SHEWMAKER | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | MEG | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PROGRAM OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 8102387226 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LMSW | ||||||||
| NPICertificationDate: | 10/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3245S0500X | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | Substance Abuse Treatment, Children |
ID Information
| ID | Type | State | Issuer | Description | 2595664 | 05 | MI | MEDICAID |