Healthcare Provider Details

I. General information

NPI: 1275441446
Provider Name (Legal Business Name): ELISHA WALLACE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13751 S WADSWORTH PARK DR STE 103
DRAPER UT
84020-2103
US

IV. Provider business mailing address

1376 W MAHOGANY ST
SARATOGA SPRINGS UT
84045-5907
US

V. Phone/Fax

Practice location:
  • Phone: 801-978-3236
  • Fax:
Mailing address:
  • Phone: 801-310-4370
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number14201269-6009
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: