Healthcare Provider Details

I. General information

NPI: 1912108390
Provider Name (Legal Business Name): ODYSSEY HOUSE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 10/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

367 SHAKER RD
CANTERBURY NH
03224-2736
US

IV. Provider business mailing address

30 WINNACUNNET RD P.O. BOX 479
HAMPTON NH
03842-2121
US

V. Phone/Fax

Practice location:
  • Phone: 603-783-7016
  • Fax: 603-783-0358
Mailing address:
  • Phone: 603-758-1550
  • Fax: 603-758-1522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0050X
TaxonomyNon-Surgical Family Planning Clinic/Center
License Number5564
License Number StateNH

VIII. Authorized Official

Name: ERIK B. JOHANNESSEN
Title or Position: CEO
Credential: LICSW
Phone: 603-758-1590