Provider Demographics
NPI:1003268293
Name:ODEGARD, STEPHANIE (MA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:ODEGARD
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1811 WEIR DR
Mailing Address - Street 2:SUTIE 270
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-2272
Mailing Address - Country:US
Mailing Address - Phone:651-714-9646
Mailing Address - Fax:
Practice Address - Street 1:1811 WEIR DR
Practice Address - Street 2:SUTIE 270
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2272
Practice Address - Country:US
Practice Address - Phone:651-714-9646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-12
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health