MEDICARE: PHYLLIS RUNDHAUG LPC AND LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	9968	TX
2	106H00000X	Marriage & Family Therapist	2049	TX

General Provider Information

NPI Number	:	1104228691
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHYLLIS RUNDHAUG LPC AND LMFT

Provider Business Mailing Address
First Line	:	15411 BANFF
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77062
Country	:	US
Telephone Number	:	281-281-0086
Fax Number	:

Provider Business Practice Location Address
First Line	:	15411 BANFF ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77062-3404
Country	:	US
Telephone Number	:	281-281-0086
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/16/2014
Last Update Date	:	09/16/2014

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