Healthcare Provider Details

I. General information

NPI: 1972624286
Provider Name (Legal Business Name): KEVIN AMDAHL MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 04/02/2025
Certification Date: 04/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2848 2ND ST S STE 185
SAINT CLOUD MN
56301-3708
US

IV. Provider business mailing address

2848 2ND STREET SOUTH 185
SAINT CLOUD MN
56301-4810
US

V. Phone/Fax

Practice location:
  • Phone: 320-252-0094
  • Fax:
Mailing address:
  • Phone: 320-252-0094
  • Fax: 320-252-0365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number748-156
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number6055
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: