Healthcare Provider Details

I. General information

NPI: 1730332586
Provider Name (Legal Business Name): MARK PATRICK ODLAND MA, LMFT, MDIV
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2008
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4910 CONSTELLATION DR
WHITE BEAR LAKE MN
55127-2218
US

IV. Provider business mailing address

4910 CONSTELLATION DR
WHITE BEAR LAKE MN
55127-2218
US

V. Phone/Fax

Practice location:
  • Phone: 651-243-2484
  • Fax: 651-925-0045
Mailing address:
  • Phone: 651-243-2484
  • Fax: 651-925-0045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number2081
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: