Basic Information
| Provider Information | |||||||||
| NPI: | 1295123230 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LONGIE | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MAPC, MAHR, LADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3004 | ||||||||
| Address2: | |||||||||
| City: | BEMIDJI | ||||||||
| State: | MN | ||||||||
| PostalCode: | 566193004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2184445155 | ||||||||
| FaxNumber: | 2183333921 | ||||||||
| Practice Location | |||||||||
| Address1: | 403 4TH ST NW | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | BEMIDJI | ||||||||
| State: | MN | ||||||||
| PostalCode: | 566013142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2184445155 | ||||||||
| FaxNumber: | 2183333291 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2014 | ||||||||
| LastUpdateDate: | 12/29/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 304052 | MN | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.