Healthcare Provider Details

I. General information

NPI: 1619091659
Provider Name (Legal Business Name): ODYSSEY PROGRAMS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 09/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 HIGHWAY 55
HASTINGS MN
55003
US

IV. Provider business mailing address

550 MAIN STR #230
NEW BRIGHTON MN
55112
US

V. Phone/Fax

Practice location:
  • Phone: 651-438-8219
  • Fax: 651-438-8252
Mailing address:
  • Phone: 612-326-7600
  • Fax: 612-326-7549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1023927
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number10239271CDT
License Number StateMN

VIII. Authorized Official

Name: PAUL ALAN LINDEMAN
Title or Position: DIRECTOR - REVENUE CYCLE MANAGEMENT
Credential:
Phone: 612-326-7566