Provider Demographics
NPI:1386072320
Name:RUNYON, RYAN (RAS, CSC,CAS)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:RUNYON
Suffix:
Gender:M
Credentials:RAS, CSC,CAS
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 626
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CA
Mailing Address - Zip Code:95461-0626
Mailing Address - Country:US
Mailing Address - Phone:707-987-9972
Mailing Address - Fax:707-987-2591
Practice Address - Street 1:10155 SOCRATES MINE ROAD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CA
Practice Address - Zip Code:95461-0626
Practice Address - Country:US
Practice Address - Phone:707-987-9972
Practice Address - Fax:707-987-2591
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-30
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA03-075996101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA03-075996OtherCAS