Healthcare Provider Details

I. General information

NPI: 1851742001
Provider Name (Legal Business Name): AMANDA LIESTA MASELLIS CADC-I, SUDC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2016
Last Update Date: 11/06/2020
Certification Date: 11/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 E 5900 S STE 101
MURRAY UT
84107-7256
US

IV. Provider business mailing address

164 E 5900 S STE 101
MURRAY UT
84107-7256
US

V. Phone/Fax

Practice location:
  • Phone: 801-261-5790
  • Fax: 801-261-5794
Mailing address:
  • Phone: 801-261-5790
  • Fax: 801-261-5794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCI10940218
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number11822780-6006
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: