Healthcare Provider Details

I. General information

NPI: 1346768496
Provider Name (Legal Business Name): AMANDA OGDAHL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: AMANDA OGDAHL MS, LPCC

II. Dates (important events)

Enumeration Date: 09/08/2017
Last Update Date: 07/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 BROADWAY ST STE 206
ALEXANDRIA MN
56308-1482
US

IV. Provider business mailing address

450 22ND AVE NW
GLENWOOD MN
56334-4547
US

V. Phone/Fax

Practice location:
  • Phone: 320-762-1762
  • Fax:
Mailing address:
  • Phone: 612-325-6707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCC01552
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: