Provider Demographics
NPI:1558005884
Name:TAUTKUS, ELISE MICHELLE (PTA)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:MICHELLE
Last Name:TAUTKUS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7856 S WOODMAN CT
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-7843
Mailing Address - Country:US
Mailing Address - Phone:801-856-4942
Mailing Address - Fax:
Practice Address - Street 1:9361 S 300 E
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-2902
Practice Address - Country:US
Practice Address - Phone:801-826-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-22
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11629847-2402225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant