Provider Demographics
NPI:1114189800
Name:ODEGARD, MARK EDWARD (PSW II)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:EDWARD
Last Name:ODEGARD
Suffix:
Gender:M
Credentials:PSW II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 AGUAJITO RD
Mailing Address - Street 2:
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93940-4887
Mailing Address - Country:US
Mailing Address - Phone:831-647-7652
Mailing Address - Fax:
Practice Address - Street 1:1200 AGUAJITO RD
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940-4887
Practice Address - Country:US
Practice Address - Phone:831-647-7652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAACSW173461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical