Provider Demographics
NPI:1629806955
Name:HIGASHIYAMA, MICHAELA SOFIA (LCSW)
Entity type:Individual
Prefix:
First Name:MICHAELA
Middle Name:SOFIA
Last Name:HIGASHIYAMA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MICHAELA
Other - Middle Name:SOFIA
Other - Last Name:JENDRYSIK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1055 N 500 W
Mailing Address - Street 2:ATTN CREDENTIALING
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:2850 N 2000 W STE 101
Practice Address - Street 2:
Practice Address - City:FARR WEST
Practice Address - State:UT
Practice Address - Zip Code:84404-9230
Practice Address - Country:US
Practice Address - Phone:801-528-5095
Practice Address - Fax:801-528-5094
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-26
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LCSW-LIC-722951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical