Provider Demographics
NPI:1063685840
Name:RUNYAN, PHILLIP
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:RUNYAN
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:PO BOX 108
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:AR
Mailing Address - Zip Code:71929-0108
Mailing Address - Country:US
Mailing Address - Phone:501-865-3363
Mailing Address - Fax:
Practice Address - Street 1:3399 FINCH RD
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:AR
Practice Address - Zip Code:71929-7541
Practice Address - Country:US
Practice Address - Phone:501-865-3363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-11
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional