Provider Demographics
NPI:1922401710
Name:ODEGARD, DEB (COTA/L)
Entity Type:Individual
Prefix:
First Name:DEB
Middle Name:
Last Name:ODEGARD
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58122-4520
Mailing Address - Country:US
Mailing Address - Phone:701-234-5608
Mailing Address - Fax:
Practice Address - Street 1:801 N BROADWAY
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58122-4520
Practice Address - Country:US
Practice Address - Phone:701-234-5608
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-07
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND375224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant