Provider Demographics
NPI:1912108390
Name:ODYSSEY HOUSE, INC.
Entity Type:Organization
Organization Name:ODYSSEY HOUSE, INC.
Other - Org Name:ODYSSEYNH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ERIK
Authorized Official - Middle Name:B
Authorized Official - Last Name:JOHANNESSEN
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:603-758-1590
Mailing Address - Street 1:30 WINNACUNNET RD
Mailing Address - Street 2:P.O. BOX 479
Mailing Address - City:HAMPTON
Mailing Address - State:NH
Mailing Address - Zip Code:03842-2121
Mailing Address - Country:US
Mailing Address - Phone:603-758-1550
Mailing Address - Fax:603-758-1522
Practice Address - Street 1:367 SHAKER RD
Practice Address - Street 2:
Practice Address - City:CANTERBURY
Practice Address - State:NH
Practice Address - Zip Code:03224-2736
Practice Address - Country:US
Practice Address - Phone:603-783-7016
Practice Address - Fax:603-783-0358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH5564261QF0050X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0050XAmbulatory Health Care FacilitiesClinic/CenterFamily Planning, Non-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30008949Medicaid