Provider Demographics
NPI:1235341785
Name:ODEGARD, MAMIKO (PHD)
Entity Type:Individual
Prefix:DR
First Name:MAMIKO
Middle Name:
Last Name:ODEGARD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10250 N 92ND ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-4510
Mailing Address - Country:US
Mailing Address - Phone:480-391-1184
Mailing Address - Fax:480-391-9717
Practice Address - Street 1:10250 N 92ND ST
Practice Address - Street 2:SUITE 303
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-4510
Practice Address - Country:US
Practice Address - Phone:480-391-1184
Practice Address - Fax:480-391-9717
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-05
Last Update Date:2008-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1113103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist