Healthcare Provider Details

I. General information

NPI: 1659742187
Provider Name (Legal Business Name): HEIDI KENNEY MARKS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2015
Last Update Date: 04/16/2026
Certification Date: 04/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 S STATE ST ST S2300
SALT LAKE CITY UT
84190-0001
US

IV. Provider business mailing address

7601 S REDWOOD RD
WEST JORDAN UT
84084-4007
US

V. Phone/Fax

Practice location:
  • Phone: 385-468-4738
  • Fax:
Mailing address:
  • Phone: 801-233-8670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1113273-6018
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: