Provider Demographics
NPI:1730323361
Name:CHILDREN'S ODYSSEY
Entity Type:Organization
Organization Name:CHILDREN'S ODYSSEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:GLOVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-878-8868
Mailing Address - Street 1:PO BOX 6038
Mailing Address - Street 2:
Mailing Address - City:FALMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04105-6038
Mailing Address - Country:US
Mailing Address - Phone:207-878-8868
Mailing Address - Fax:207-878-8810
Practice Address - Street 1:110 DAVIS FARM RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-1604
Practice Address - Country:US
Practice Address - Phone:207-878-8868
Practice Address - Fax:207-878-8810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-27
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME124890000Medicaid