Provider Demographics
NPI:1477878080
Name:REYES-RUNYON, ELENA DANIELLE (LMHC, BCBA)
Entity Type:Individual
Prefix:MRS
First Name:ELENA
Middle Name:DANIELLE
Last Name:REYES-RUNYON
Suffix:
Gender:F
Credentials:LMHC, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4432 BLUE BILL PASS
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32303-6936
Mailing Address - Country:US
Mailing Address - Phone:850-933-0218
Mailing Address - Fax:
Practice Address - Street 1:1607 VILLAGE SQUARE BLVD STE 5
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32309-2772
Practice Address - Country:US
Practice Address - Phone:850-727-4757
Practice Address - Fax:850-765-6298
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-07
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
FLMH10193101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002065300Medicaid