Provider Demographics
NPI:1457053142
Name:DEHART-RUNYEON, MEGAN EMILY
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:EMILY
Last Name:DEHART-RUNYEON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11318 OHIO AVE UNIT 1
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-3210
Mailing Address - Country:US
Mailing Address - Phone:660-624-0099
Mailing Address - Fax:
Practice Address - Street 1:4221 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-3512
Practice Address - Country:US
Practice Address - Phone:424-256-3693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA137571103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical