Healthcare Provider Details

I. General information

NPI: 1629926142
Provider Name (Legal Business Name): CANDISE MICHELLE HEINER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CANDISE MICHELLE MASON

II. Dates (important events)

Enumeration Date: 03/19/2026
Last Update Date: 03/19/2026
Certification Date: 03/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5314 N RIVER RUN DR
PROVO UT
84604-5691
US

IV. Provider business mailing address

5314 N RIVER RUN DR
PROVO UT
84604-5691
US

V. Phone/Fax

Practice location:
  • Phone: 801-787-9855
  • Fax: 801-228-1756
Mailing address:
  • Phone: 801-787-9855
  • Fax: 801-228-1756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number287927-6009
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: