Provider Demographics
NPI:1902319551
Name:BRUNNER, REGINA (ACMHC, RN)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:BRUNNER
Suffix:
Gender:
Credentials:ACMHC, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5455 W 11000 N STE 201
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:UT
Mailing Address - Zip Code:84003-8820
Mailing Address - Country:US
Mailing Address - Phone:801-449-0017
Mailing Address - Fax:
Practice Address - Street 1:5455 W 11000 N STE 201
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:UT
Practice Address - Zip Code:84003-8820
Practice Address - Country:US
Practice Address - Phone:801-449-0017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-06
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14179257-3102163W00000X
UT14199401-6009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No163W00000XNursing Service ProvidersRegistered Nurse