Basic Information
| Provider Information | |||||||||
| NPI: | 1003948845 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUNDHAUG | ||||||||
| FirstName: | BERNADETTE | ||||||||
| MiddleName: | JAMIE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MED | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 137 | ||||||||
| Address2: | |||||||||
| City: | COTTONWOOD | ||||||||
| State: | ID | ||||||||
| PostalCode: | 835220137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2089623251 | ||||||||
| FaxNumber: | 2089622478 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 LEWISTON ST | ||||||||
| Address2: | |||||||||
| City: | COTTONWOOD | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2089623251 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2007 | ||||||||
| LastUpdateDate: | 10/17/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | LCPC-7085 | ID | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.