MEDICARE: FLINT ODYSSEY HOUSE, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	SA0250303	MI

General Provider Information

NPI Number	:	1194112771
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FLINT ODYSSEY HOUSE, INC.

Provider Business Mailing Address
First Line	:	529 MARTIN LUTHER KING JR AVE
Second Line	:
City	:	FLINT
State	:	MI
Zip	:	48502
Country	:	US
Telephone Number	:	810-238-7226
Fax Number	:

Provider Business Practice Location Address
First Line	:	1431 LAPEER AVE
Second Line	:
City	:	PORT HURON
State	:	MI
Zip	:	48060-4277
Country	:	US
Telephone Number	:	810-238-7226
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATIVE DIRECTOR
Name	:	MS. KIMBERLY MEG SHEWMAKER
Credential	:	LMSW, CAADC, CCDP-D,
Telephone Number	:	810-238-7226

Provider Enumeration Date	:	04/21/2015
Last Update Date	:	10/20/2021

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