Provider Demographics
NPI:1346768496
Name:OGDAHL, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:OGDAHL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:OGDAHL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, LPCC
Mailing Address - Street 1:450 22ND AVE NW
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:56334-4547
Mailing Address - Country:US
Mailing Address - Phone:612-325-6707
Mailing Address - Fax:
Practice Address - Street 1:324 BROADWAY ST STE 206
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-1482
Practice Address - Country:US
Practice Address - Phone:320-762-1762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-08
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC01552101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNCC01552Medicaid