MEDICARE: ALICIA ANTOINETTE RUNYAN LCSW

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	1041C0700X	Clinical Social Worker	9752-C	NV

General Provider Information

NPI Number	:	1821641242
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALICIA ANTOINETTE RUNYAN LCSW

Provider Business Mailing Address
First Line	:	2400 N TENAYA WAY STE 301
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-0645
Country	:	US
Telephone Number	:	725-222-0263
Fax Number	:	725-262-5630

Provider Business Practice Location Address
First Line	:	2400 N TENAYA WAY STE 301
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-0645
Country	:	US
Telephone Number	:	725-222-0263
Fax Number	:

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

Provider Enumeration Date	:	07/24/2019
Last Update Date	:	06/24/2025

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