Provider Demographics
NPI:1669946570
Name:RUNCIE, KIMARA ROSITA (NCC)
Entity type:Individual
Prefix:MRS
First Name:KIMARA
Middle Name:ROSITA
Last Name:RUNCIE
Suffix:
Gender:F
Credentials:NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:286 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-4512
Mailing Address - Country:US
Mailing Address - Phone:718-236-0774
Mailing Address - Fax:
Practice Address - Street 1:286 5TH AVE UNIT 1001
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-4512
Practice Address - Country:US
Practice Address - Phone:718-236-0774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-14
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GANCC283378101YM0800X
NY009861101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health