Provider Demographics
NPI:1104592617
Name:ODYSSEY MENTAL HEALTH CARE LLC
Entity type:Organization
Organization Name:ODYSSEY MENTAL HEALTH CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-827-2987
Mailing Address - Street 1:PO BOX 523882
Mailing Address - Street 2:C/O THE MAILBOX #10649
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33152-9265
Mailing Address - Country:US
Mailing Address - Phone:317-827-2987
Mailing Address - Fax:317-219-0879
Practice Address - Street 1:3203 DOGWOOD LN
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-9629
Practice Address - Country:US
Practice Address - Phone:317-827-2987
Practice Address - Fax:317-219-0879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-17
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty