Provider Demographics
NPI:1770872038
Name:RUNNELS, LINDA
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:RUNNELS
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 1:1120 BONAIR DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-9335
Mailing Address - Country:US
Mailing Address - Phone:570-323-7077
Mailing Address - Fax:
Practice Address - Street 1:1120 BONAIR DR
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-9335
Practice Address - Country:US
Practice Address - Phone:570-323-7077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-06
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA080128589235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1275739955Medicaid