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General NPI Number Information
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NPI Number | 1194112771
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Entity Type | Organization
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Legal Business Name | FLINT ODYSSEY HOUSE, INC.
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Dates
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Enumeration Date | 04/21/2015
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Last Update Date | 10/20/2021
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Provider Practice Location Address
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Address Line | 1431 LAPEER AVE
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City | PORT HURON
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State | MI
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Zip | 48060-4277
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Country | US
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Telephone | 810-238-7226
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Fax |
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Provider Business Mailing Address
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Address Line | 529 MARTIN LUTHER KING JR AVE
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City | FLINT
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State | MI
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Zip | 48502
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Country | US
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Telephone | 810-238-7226
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATIVE DIRECTOR
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Name | MS. KIMBERLY MEG SHEWMAKER
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Credential | LMSW, CAADC, CCDP-D,
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Telephone | 810-238-7226
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | SA0250303
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License Number State | MI
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