Provider Demographics
NPI:1619608189
Name:DA COSTA RESTA, ADILVANIA F
Entity type:Individual
Prefix:
First Name:ADILVANIA
Middle Name:F
Last Name:DA COSTA RESTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2576 S 900 E APT 2
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-2556
Mailing Address - Country:US
Mailing Address - Phone:954-773-1050
Mailing Address - Fax:
Practice Address - Street 1:777 E 3900 S
Practice Address - Street 2:
Practice Address - City:MILLCREEK
Practice Address - State:UT
Practice Address - Zip Code:84107-2199
Practice Address - Country:US
Practice Address - Phone:954-773-1050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-23
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10173086-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist