Provider Demographics
NPI:1073233540
Name:RUNYON, KAITLYN TAYLOR (PLMHP PCMSW)
Entity Type:Individual
Prefix:MRS
First Name:KAITLYN
Middle Name:TAYLOR
Last Name:RUNYON
Suffix:
Gender:F
Credentials:PLMHP PCMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10899 POLK ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-4700
Mailing Address - Country:US
Mailing Address - Phone:402-968-2816
Mailing Address - Fax:
Practice Address - Street 1:15705 W DODGE RD SUITE 102
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68118
Practice Address - Country:US
Practice Address - Phone:402-575-5577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-02
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE126371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical