Provider Demographics
NPI:1538612262
Name:ODLAND, DIANE
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:ODLAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 8TH AVE W
Mailing Address - Street 2:
Mailing Address - City:SISSETON
Mailing Address - State:SD
Mailing Address - Zip Code:57262-1262
Mailing Address - Country:US
Mailing Address - Phone:605-698-7613
Mailing Address - Fax:
Practice Address - Street 1:516 8TH AVE W
Practice Address - Street 2:
Practice Address - City:SISSETON
Practice Address - State:SD
Practice Address - Zip Code:57262-1262
Practice Address - Country:US
Practice Address - Phone:605-698-7613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-29
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD317-LIMITED235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist