Healthcare Provider Details

I. General information

NPI: 1497109078
Provider Name (Legal Business Name): ODYSSEY HOUSE OF LA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2016
Last Update Date: 04/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 N TONTI ST
NEW ORLEANS LA
70119-3549
US

IV. Provider business mailing address

1125 N TONTI ST
NEW ORLEANS LA
70119-3549
US

V. Phone/Fax

Practice location:
  • Phone: 504-821-9211
  • Fax:
Mailing address:
  • Phone: 504-821-9211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number3991
License Number StateLA

VIII. Authorized Official

Name: MRS. ANDREA LEE
Title or Position: ADMISSION COUNSELOR
Credential: LAC, LPC
Phone: 504-821-9211