Provider Demographics
NPI:1194496687
Name:RUNDLE, BRIAN
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:RUNDLE
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 1:1400 34TH AVE SW APT 409
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:IA
Mailing Address - Zip Code:50009-5459
Mailing Address - Country:US
Mailing Address - Phone:641-777-7174
Mailing Address - Fax:
Practice Address - Street 1:6200 AURORA AVE STE 401E
Practice Address - Street 2:
Practice Address - City:URBANDALE
Practice Address - State:IA
Practice Address - Zip Code:50322-2866
Practice Address - Country:US
Practice Address - Phone:515-331-0303
Practice Address - Fax:515-331-9086
Is Sole Proprietor?:No
Enumeration Date:2021-09-23
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA108305106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist