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General NPI Number Information
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NPI Number | 1215891221
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Entity Type | Individual
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Provider Name | ELISE SHANTHANI VADIVELOO
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Gender | Female
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Dates
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Enumeration Date | 12/13/2025
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Last Update Date | 12/13/2025
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Provider Practice Location Address
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Address Line | 14787 S ACADEMY PKWY
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City | HERRIMAN
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State | UT
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Zip | 84096-2077
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Country | US
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Telephone | 385-434-3118
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Fax |
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Provider Business Mailing Address
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Address Line | 152 E MIDVILLAGE BLVD APT 209
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City | SANDY
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State | UT
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Zip | 84070-1375
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Country | US
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Telephone | 385-464-7942
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 14212533-2401
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License Number State | UT
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