Provider Demographics
NPI:1821605684
Name:ODEGAARD, PETER
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:ODEGAARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 ELM ST
Mailing Address - Street 2:
Mailing Address - City:WEBSTER CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50595-1925
Mailing Address - Country:US
Mailing Address - Phone:515-297-2041
Mailing Address - Fax:
Practice Address - Street 1:1200 VALLEY WEST DR
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-1908
Practice Address - Country:US
Practice Address - Phone:515-267-1340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-25
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPCC.0017849101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health