Healthcare Provider Details

I. General information

NPI: 1699130179
Provider Name (Legal Business Name): KRISTINA LYNN RUNGE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2015
Last Update Date: 12/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 SIERRA COLLEGE DR
GRASS VALLEY CA
95945-5768
US

IV. Provider business mailing address

180 SIERRA COLLEGE DR
GRASS VALLEY CA
95945-5768
US

V. Phone/Fax

Practice location:
  • Phone: 530-878-5166
  • Fax: 530-271-7036
Mailing address:
  • Phone: 530-878-5166
  • Fax: 530-271-7036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: