Healthcare Provider Details

I. General information

NPI: 1164525978
Provider Name (Legal Business Name): RAYMOND J ODIORNE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56 CHURCH ST
WATERBURY CT
06702-2103
US

IV. Provider business mailing address

136 WOODSIDE AVE
WATERBURY CT
06708-2504
US

V. Phone/Fax

Practice location:
  • Phone: 203-755-1196
  • Fax: 203-575-9675
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number000278
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: