Provider Demographics
NPI:1285202846
Name:RUNCK, HALLE OPAL
Entity Type:Individual
Prefix:
First Name:HALLE
Middle Name:OPAL
Last Name:RUNCK
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 1:2419 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:MONTEVIDEO
Mailing Address - State:MN
Mailing Address - Zip Code:56265-2619
Mailing Address - Country:US
Mailing Address - Phone:320-321-1484
Mailing Address - Fax:
Practice Address - Street 1:2419 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MONTEVIDEO
Practice Address - State:MN
Practice Address - Zip Code:56265-2619
Practice Address - Country:US
Practice Address - Phone:320-321-1484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-11
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician