Provider Demographics
NPI:1710197942
Name:ODEGARD, MELISSA (LPC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:ODEGARD
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 N 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4053
Mailing Address - Country:US
Mailing Address - Phone:208-236-1600
Mailing Address - Fax:
Practice Address - Street 1:500 S 11TH AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4835
Practice Address - Country:US
Practice Address - Phone:208-233-0150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
IDLPC369101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health