Provider Demographics
NPI:1801162995
Name:ODYSSEY HOUSE
Entity type:Organization
Organization Name:ODYSSEY HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF BUSINESS OPS
Authorized Official - Prefix:
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:
Authorized Official - Last Name:TILLETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-428-3487
Mailing Address - Street 1:350 E 2100 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84115-2266
Mailing Address - Country:US
Mailing Address - Phone:801-322-1185
Mailing Address - Fax:801-322-4002
Practice Address - Street 1:350 E 2100 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-2266
Practice Address - Country:US
Practice Address - Phone:801-322-1185
Practice Address - Fax:801-322-4002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-22
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11881261QM0801X, 261QM0850X, 261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health