Provider Demographics
NPI:1386517274
Name:KUCZINNA, SIMON
Entity type:Individual
Prefix:
First Name:SIMON
Middle Name:
Last Name:KUCZINNA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3559 S MONTCLAIR ST
Mailing Address - Street 2:
Mailing Address - City:MAGNA
Mailing Address - State:UT
Mailing Address - Zip Code:84044-2474
Mailing Address - Country:US
Mailing Address - Phone:385-216-4046
Mailing Address - Fax:
Practice Address - Street 1:14551 SENTINEL RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:HERRIMAN
Practice Address - State:UT
Practice Address - Zip Code:84096
Practice Address - Country:US
Practice Address - Phone:801-957-6625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-26
Last Update Date:2025-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)