Healthcare Provider Details

I. General information

NPI: 1669317194
Provider Name (Legal Business Name): JUSTIN RUNQUIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2026
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 S RIVER RD APT 207
DES PLAINES IL
60016-4783
US

IV. Provider business mailing address

555 S RIVER RD APT 207
DES PLAINES IL
60016-4783
US

V. Phone/Fax

Practice location:
  • Phone: 630-338-9721
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: