Provider Demographics
NPI:1912129495
Name:ODYSSEY COUNSELING LLC
Entity Type:Organization
Organization Name:ODYSSEY COUNSELING LLC
Other - Org Name:ODYSSEY COUNSELING & CONSULTATIONS INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:F
Authorized Official - Last Name:BACA
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:505-315-7397
Mailing Address - Street 1:5212 PARK HEIGHTS RD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120
Mailing Address - Country:US
Mailing Address - Phone:505-315-7397
Mailing Address - Fax:505-345-2127
Practice Address - Street 1:5827 4TH ST NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107
Practice Address - Country:US
Practice Address - Phone:505-315-7397
Practice Address - Fax:505-345-2127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0983101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty