Provider Demographics
NPI:1114688660
Name:PROJECT ODYSSEY ABA, LLC
Entity Type:Organization
Organization Name:PROJECT ODYSSEY ABA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/BEHAVIOR ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:DOMINIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROUGEAU
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA, LBA, MA
Authorized Official - Phone:337-292-5906
Mailing Address - Street 1:815 GASS AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-2303
Mailing Address - Country:US
Mailing Address - Phone:337-602-8884
Mailing Address - Fax:618-418-4422
Practice Address - Street 1:815 GASS AVE
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-2303
Practice Address - Country:US
Practice Address - Phone:337-602-8884
Practice Address - Fax:618-418-4422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-06
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty