MEDICARE: KIMBERLEY DIANA ODEGAARD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1023440617
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLEY DIANA ODEGAARD

Provider Business Mailing Address
First Line	:	1105 W RUSSELL ST
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57104-1322
Country	:	US
Telephone Number	:	605-271-2690
Fax Number	:	605-271-3956

Provider Business Practice Location Address
First Line	:	3721 23RD ST S STE 201
Second Line	:
City	:	SAINT CLOUD
State	:	MN
Zip	:	56301-6199
Country	:	US
Telephone Number	:	605-271-2690
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/06/2013
Last Update Date	:	04/17/2024

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Directions to “ KIMBERLEY DIANA ODEGAARD ” Practice Location

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