Provider Demographics
NPI:1568650778
Name:ODEGAARD, ROBERT WAYNE (LADC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:WAYNE
Last Name:ODEGAARD
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7616 CURRELL BLVD
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-2290
Mailing Address - Country:US
Mailing Address - Phone:651-259-9750
Mailing Address - Fax:651-259-9790
Practice Address - Street 1:7616 CURRELL BLVD
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2290
Practice Address - Country:US
Practice Address - Phone:651-259-9750
Practice Address - Fax:651-259-9790
Is Sole Proprietor?:No
Enumeration Date:2007-10-12
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN301997101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)