Provider Demographics
NPI:1417463340
Name:RUNYAN, EMILY BROOKE (LCSW)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:BROOKE
Last Name:RUNYAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1807 N NASHVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60707-3911
Mailing Address - Country:US
Mailing Address - Phone:312-420-3193
Mailing Address - Fax:
Practice Address - Street 1:1147 N WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-2931
Practice Address - Country:US
Practice Address - Phone:312-420-3193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-14
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0140331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical