MEDICARE: KAELEA ROSE WAGAMAN-HASSELSTROM ALSUDC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	12592546-6008	UT

General Provider Information

NPI Number	:	1598416349
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAELEA ROSE WAGAMAN-HASSELSTROM ALSUDC

Provider Business Mailing Address
First Line	:	716 N 900 W APT 106
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84116-4014
Country	:	US
Telephone Number	:	425-374-9449
Fax Number	:

Provider Business Practice Location Address
First Line	:	950 E 3300 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-2141
Country	:	US
Telephone Number	:	801-359-8862
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/13/2022
Last Update Date	:	01/13/2022

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