Provider Demographics
NPI:1902412141
Name:RUNYAN, TERIESA BLACK (LMT)
Entity Type:Individual
Prefix:
First Name:TERIESA
Middle Name:BLACK
Last Name:RUNYAN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 WILLOW CREEK CT
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-1316
Mailing Address - Country:US
Mailing Address - Phone:801-706-6330
Mailing Address - Fax:
Practice Address - Street 1:1308 12TH AVE S
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-4607
Practice Address - Country:US
Practice Address - Phone:406-453-8885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-22
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT260024-4701225700000X
MTLMT-LMT-LIC-17904225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist