=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356677694
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MASATA, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2009
-----------------------------------------------------
Last Update Date | 10/21/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 549 MIDDLEBURG ST.
-----------------------------------------------------
City | LIBERTY
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42539
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-787-1950
-----------------------------------------------------
Fax | 606-787-0123
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1116
-----------------------------------------------------
City | LIBERTY
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42539-1116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-787-1950
-----------------------------------------------------
Fax | 606-787-0123
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL DIRECTOR, THERAPIST
-----------------------------------------------------
Name | MR. C. NATHAN MCANELLY
-----------------------------------------------------
Credential | MSW, CSW
-----------------------------------------------------
Telephone | 606-787-1950
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 810273
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------