Provider Demographics
NPI:1609246677
Name:LOGAN, AMANDA (MSW, LICSW)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:LOGAN
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 WESTRAC DR S
Mailing Address - Street 2:SUITE 400
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-2338
Mailing Address - Country:US
Mailing Address - Phone:107-280-9545
Mailing Address - Fax:701-280-9520
Practice Address - Street 1:1202 WESTRAC DR S
Practice Address - Street 2:SUITE 400
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-2338
Practice Address - Country:US
Practice Address - Phone:107-280-9545
Practice Address - Fax:701-280-9520
Is Sole Proprietor?:No
Enumeration Date:2015-10-02
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN16371104100000X
ND4408104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1465561Medicaid