Provider Demographics
NPI:1336455740
Name:FARGO, AMANDA E (PSYD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:E
Last Name:FARGO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 MISSION ST STE 106
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-3687
Mailing Address - Country:US
Mailing Address - Phone:831-246-0456
Mailing Address - Fax:
Practice Address - Street 1:231A MAIN ST
Practice Address - Street 2:
Practice Address - City:BEN LOMOND
Practice Address - State:CA
Practice Address - Zip Code:95005-9394
Practice Address - Country:US
Practice Address - Phone:831-246-0456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-23
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21619103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical