Healthcare Provider Details

I. General information

NPI: 1518852839
Provider Name (Legal Business Name): MS. ADELINE RAE CHAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2025
Last Update Date: 06/09/2025
Certification Date: 06/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3855 S 700 E
MILLCREEK UT
84106-1157
US

IV. Provider business mailing address

3855 S 700 E
MILLCREEK UT
84106-1157
US

V. Phone/Fax

Practice location:
  • Phone: 801-268-4766
  • Fax:
Mailing address:
  • Phone: 801-268-4766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code226000000X
TaxonomyRecreational Therapist Assistant
License Number14200801-4003
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: