Provider Demographics
NPI:1104324631
Name:RUNYON, GREGORY W (LCDC III 162038)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:W
Last Name:RUNYON
Suffix:
Gender:M
Credentials:LCDC III 162038
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2903 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:IRONTON
Mailing Address - State:OH
Mailing Address - Zip Code:45638-2866
Mailing Address - Country:US
Mailing Address - Phone:740-646-6640
Mailing Address - Fax:866-475-7263
Practice Address - Street 1:2903 S 5TH ST
Practice Address - Street 2:
Practice Address - City:IRONTON
Practice Address - State:OH
Practice Address - Zip Code:45638-2866
Practice Address - Country:US
Practice Address - Phone:740-646-6640
Practice Address - Fax:866-475-7263
Is Sole Proprietor?:No
Enumeration Date:2018-01-30
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDCIII.162038101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0295280Medicaid