Provider Demographics
NPI:1154647915
Name:RUNFELDT, PHILIP ANDREW (BCABA)
Entity Type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:ANDREW
Last Name:RUNFELDT
Suffix:
Gender:M
Credentials:BCABA
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 410286
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32941-0286
Mailing Address - Country:US
Mailing Address - Phone:321-441-3925
Mailing Address - Fax:800-728-0287
Practice Address - Street 1:550 SAINT JOHNS ST
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32922-7241
Practice Address - Country:US
Practice Address - Phone:321-639-9800
Practice Address - Fax:321-639-6007
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-19
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0-09-3692103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst