Healthcare Provider Details

I. General information

NPI: 1386517274
Provider Name (Legal Business Name): SIMON KUCZINNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2025
Last Update Date: 09/26/2025
Certification Date: 09/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14551 SENTINEL RIDGE BLVD
HERRIMAN UT
84096
US

IV. Provider business mailing address

3559 S MONTCLAIR ST
MAGNA UT
84044-2474
US

V. Phone/Fax

Practice location:
  • Phone: 801-957-6625
  • Fax:
Mailing address:
  • Phone: 385-216-4046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: