Healthcare Provider Details

I. General information

NPI: 1194661546
Provider Name (Legal Business Name): AMANDA GRACE FOGUS CSWA, CHW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2026
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 E BROADWAY STE 431
EUGENE OR
97401-3158
US

IV. Provider business mailing address

132 E BROADWAY STE 431
EUGENE OR
97401-3158
US

V. Phone/Fax

Practice location:
  • Phone: 541-321-0517
  • Fax:
Mailing address:
  • Phone: 541-321-0517
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberA18344
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number105155
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: