Provider Demographics
NPI:1689730665
Name:RUNGE, JONATHAN SCOTT (PSYD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:SCOTT
Last Name:RUNGE
Suffix:
Gender:M
Credentials:PSYD
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 1861
Mailing Address - Street 2:
Mailing Address - City:PROVINCETOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02657-0245
Mailing Address - Country:US
Mailing Address - Phone:617-901-1196
Mailing Address - Fax:
Practice Address - Street 1:30 CONWELL ST
Practice Address - Street 2:
Practice Address - City:PROVINCETOWN
Practice Address - State:MA
Practice Address - Zip Code:02657-1548
Practice Address - Country:US
Practice Address - Phone:617-901-1196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23772103TC0700X
MA9711103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical