Provider Demographics
NPI: | 1033143706 |
---|---|
Name: | ODYSSEY HOUSE INC |
Entity type: | Organization |
Organization Name: | ODYSSEY HOUSE INC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CEO |
Authorized Official - Prefix: | |
Authorized Official - First Name: | ADAM |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | COHEN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 801-428-3449 |
Mailing Address - Street 1: | 344 E 100 S STE 301 |
Mailing Address - Street 2: | |
Mailing Address - City: | SALT LAKE CITY |
Mailing Address - State: | UT |
Mailing Address - Zip Code: | 84111-1727 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 801-322-4257 |
Mailing Address - Fax: | 801-322-2831 |
Practice Address - Street 1: | 340 E 100 S |
Practice Address - Street 2: | |
Practice Address - City: | SALT LAKE CITY |
Practice Address - State: | UT |
Practice Address - Zip Code: | 84111-1702 |
Practice Address - Country: | US |
Practice Address - Phone: | 801-322-3222 |
Practice Address - Fax: | 801-322-2831 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-07-10 |
Last Update Date: | 2024-04-17 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
363LP0808X, 322D00000X, 323P00000X, 324500000X, 2084P0802X, 251S00000X, 261QM0801X, 261QM0855X, 101YS0200X, 1041C0700X, 1041S0200X, 101YP2500X, 106H00000X | ||
UT | 163407-1205 | 261QP2300X |
UT | 11273 | 261QR0405X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 261QR0405X | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | Group - Multi-Specialty |
No | 363LP0808X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psychiatric/Mental Health | Group - Multi-Specialty |
No | 322D00000X | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children | Group - Multi-Specialty | |
No | 323P00000X | Residential Treatment Facilities | Psychiatric Residential Treatment Facility | Group - Multi-Specialty | |
No | 324500000X | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | Group - Multi-Specialty | |
No | 2084P0802X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Psychiatry | Group - Multi-Specialty |
No | 251S00000X | Agencies | Community/Behavioral Health | Group - Multi-Specialty | |
No | 261QM0801X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | Group - Multi-Specialty |
No | 261QM0855X | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | Group - Multi-Specialty |
No | 261QP2300X | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | Group - Multi-Specialty |
No | 101YS0200X | Behavioral Health & Social Service Providers | Counselor | School | Group - Multi-Specialty |
No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
No | 1041S0200X | Behavioral Health & Social Service Providers | Social Worker | School | Group - Multi-Specialty |
No | 101YP2500X | Behavioral Health & Social Service Providers | Counselor | Professional | Group - Multi-Specialty |
No | 106H00000X | Behavioral Health & Social Service Providers | Marriage & Family Therapist | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
UT | =========001 | Medicaid | |
UT | =========028 | Medicaid | |
UT | =========028 | Medicaid |