Provider Demographics
NPI:1013367077
Name:ODEGARD, REBECCA KATHLEEN (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:KATHLEEN
Last Name:ODEGARD
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:KATHLEEN
Other - Last Name:VASEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12110 CLAYTON RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-2516
Mailing Address - Country:US
Mailing Address - Phone:314-989-8100
Mailing Address - Fax:
Practice Address - Street 1:12110 CLAYTON RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2516
Practice Address - Country:US
Practice Address - Phone:314-989-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-20
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016013011235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist