Provider Demographics
NPI:1851742001
Name:MASELLIS, AMANDA LIESTA (CADC-I, SUDC)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:LIESTA
Last Name:MASELLIS
Suffix:
Gender:F
Credentials:CADC-I, SUDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 E 5900 S STE 101
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-7256
Mailing Address - Country:US
Mailing Address - Phone:801-261-5790
Mailing Address - Fax:801-261-5794
Practice Address - Street 1:164 E 5900 S STE 101
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-7256
Practice Address - Country:US
Practice Address - Phone:801-261-5790
Practice Address - Fax:801-261-5794
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-29
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACI10940218101YA0400X
UT11822780-6006101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)