Provider Demographics
NPI:1215067681
Name:DOVETAIL HOLDINGS, INC
Entity type:Organization
Organization Name:DOVETAIL HOLDINGS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:JON
Authorized Official - Last Name:RUNGE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD PSYCHOLOGIST
Authorized Official - Phone:704-425-4791
Mailing Address - Street 1:1210 OAKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:KANNAPOLIS
Mailing Address - State:NC
Mailing Address - Zip Code:28081-5364
Mailing Address - Country:US
Mailing Address - Phone:704-425-4791
Mailing Address - Fax:704-795-7179
Practice Address - Street 1:912 COPPERFIELD BLVD NE
Practice Address - Street 2:COPPERFIELD COMMONS
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2433
Practice Address - Country:US
Practice Address - Phone:704-425-4791
Practice Address - Fax:704-795-7179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2580103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2813938BMedicare ID - Type UnspecifiedINDIVIDUAL PROVIDER #
NC2822782Medicare ID - Type UnspecifiedPSYCHOLOGY PRACTICE