Provider Demographics
NPI:1669853099
Name:ODLAND, ANTHONY (PHD, LP, ABPP)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:ODLAND
Suffix:
Gender:M
Credentials:PHD, LP, ABPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15600 36TH AVE N STE 140
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55446-3372
Mailing Address - Country:US
Mailing Address - Phone:763-308-5772
Mailing Address - Fax:612-392-7974
Practice Address - Street 1:15600 36TH AVE N STE 140
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55446-3372
Practice Address - Country:US
Practice Address - Phone:763-308-5772
Practice Address - Fax:612-392-7974
Is Sole Proprietor?:No
Enumeration Date:2015-06-11
Last Update Date:2022-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5884103G00000X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist