Provider Demographics
NPI:1477593630
Name:RUNGE, MARTHA L (PHD)
Entity Type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:L
Last Name:RUNGE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 W NATIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53295-2203
Mailing Address - Country:US
Mailing Address - Phone:414-384-2000
Mailing Address - Fax:414-382-5298
Practice Address - Street 1:5000 W NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53295-2203
Practice Address - Country:US
Practice Address - Phone:414-384-2000
Practice Address - Fax:414-382-5298
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIWI2069103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39650200Medicaid
WI39650200Medicaid