Provider Demographics
NPI:1598416349
Name:WAGAMAN-HASSELSTROM, KAELEA ROSE (ALSUDC)
Entity type:Individual
Prefix:
First Name:KAELEA
Middle Name:ROSE
Last Name:WAGAMAN-HASSELSTROM
Suffix:
Gender:F
Credentials:ALSUDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 N 900 W APT 106
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84116-4014
Mailing Address - Country:US
Mailing Address - Phone:425-374-9449
Mailing Address - Fax:
Practice Address - Street 1:950 E 3300 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-2141
Practice Address - Country:US
Practice Address - Phone:801-359-8862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-13
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12592546-6008101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)