Provider Demographics
NPI:1144013764
Name:BRUNER, KAYLAH
Entity type:Individual
Prefix:
First Name:KAYLAH
Middle Name:
Last Name:BRUNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 STOCKARD ST
Mailing Address - Street 2:
Mailing Address - City:LAKE DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75065-2669
Mailing Address - Country:US
Mailing Address - Phone:469-503-9669
Mailing Address - Fax:
Practice Address - Street 1:8111 LYNDON B JOHNSON FWY STE 900
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75251-1322
Practice Address - Country:US
Practice Address - Phone:940-721-4366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-27
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX114092104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker