Provider Demographics
NPI:1689435281
Name:KASAMA HEALTH & WELLNESS
Entity Type:Organization
Organization Name:KASAMA HEALTH & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PMHNP
Authorized Official - Prefix:
Authorized Official - First Name:LIANI
Authorized Official - Middle Name:
Authorized Official - Last Name:ECCLES
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:435-962-0130
Mailing Address - Street 1:1545 E 2000 N
Mailing Address - Street 2:
Mailing Address - City:NORTH LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-2163
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1034 RSI DR UNIT 120
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-2203
Practice Address - Country:US
Practice Address - Phone:435-512-7825
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-19
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)