Provider Demographics
NPI:1265746572
Name:KASTANES-LISTER, AMY AMELIA
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:AMELIA
Last Name:KASTANES-LISTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:AMELIA
Other - Last Name:KASTANES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:121 N 1550 W
Mailing Address - Street 2:
Mailing Address - City:CEDAR CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84720-4136
Mailing Address - Country:US
Mailing Address - Phone:435-867-8168
Mailing Address - Fax:
Practice Address - Street 1:121 N 1550 W
Practice Address - Street 2:
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84720-4136
Practice Address - Country:US
Practice Address - Phone:435-867-8168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-28
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT651186453Medicaid