Healthcare Provider Details

I. General information

NPI: 1902319551
Provider Name (Legal Business Name): REGINA BRUNNER ACMHC, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2017
Last Update Date: 03/18/2025
Certification Date: 03/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5455 W 11000 N STE 201
HIGHLAND UT
84003-8820
US

IV. Provider business mailing address

5455 W 11000 N STE 201
HIGHLAND UT
84003-8820
US

V. Phone/Fax

Practice location:
  • Phone: 801-449-0017
  • Fax:
Mailing address:
  • Phone: 801-449-0017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number14199401-6009
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number14179257-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: