Provider Demographics
NPI:1962279091
Name:ODYSSEY OF THE HEART LLC
Entity type:Organization
Organization Name:ODYSSEY OF THE HEART LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:484-802-5250
Mailing Address - Street 1:PO BOX 171
Mailing Address - Street 2:
Mailing Address - City:LEMONT
Mailing Address - State:PA
Mailing Address - Zip Code:16851-0171
Mailing Address - Country:US
Mailing Address - Phone:484-802-5250
Mailing Address - Fax:
Practice Address - Street 1:187 HONORS LN
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16803-1838
Practice Address - Country:US
Practice Address - Phone:484-802-5250
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-08
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty