Provider Demographics
NPI:1942363601
Name:ODELL, MARK (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:ODELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9864
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59904-2864
Mailing Address - Country:US
Mailing Address - Phone:406-755-5430
Mailing Address - Fax:406-755-5430
Practice Address - Street 1:33 2ND ST E
Practice Address - Street 2:SUITE 4
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-6108
Practice Address - Country:US
Practice Address - Phone:406-755-5430
Practice Address - Fax:406-755-5430
Is Sole Proprietor?:No
Enumeration Date:2006-12-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTLCPC 1164101YP2500X
NVLMFT 0776106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT742060OtherBCBS PROVIDER NUMBER