Provider Demographics
NPI:1275279291
Name:RUNGE, NEVIN JAI
Entity Type:Individual
Prefix:
First Name:NEVIN
Middle Name:JAI
Last Name:RUNGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 WILTSHIRE LN
Mailing Address - Street 2:
Mailing Address - City:VILLAGE OF LAKEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60014-5434
Mailing Address - Country:US
Mailing Address - Phone:815-323-9045
Mailing Address - Fax:
Practice Address - Street 1:309 WALNUT ST STE B
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-2766
Practice Address - Country:US
Practice Address - Phone:000-000-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-11
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician