Provider Demographics
NPI:1952549875
Name:YOUTH ODYSSEY INC.
Entity Type:Organization
Organization Name:YOUTH ODYSSEY INC.
Other - Org Name:WILDERNESS ODYSSEY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:WORBETS
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:877-834-4430
Mailing Address - Street 1:PO BOX 1065
Mailing Address - Street 2:
Mailing Address - City:RUIDOSO
Mailing Address - State:NM
Mailing Address - Zip Code:88355-1065
Mailing Address - Country:US
Mailing Address - Phone:877-834-4430
Mailing Address - Fax:575-258-3907
Practice Address - Street 1:605 WHITE MOUNTAIN MEADOWS DR
Practice Address - Street 2:
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345-5816
Practice Address - Country:US
Practice Address - Phone:877-834-4430
Practice Address - Fax:575-258-3907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-30
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4737322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children