Basic Information
| Provider Information | |||||||||
| NPI: | 1154647915 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUNFELDT | ||||||||
| FirstName: | PHILIP | ||||||||
| MiddleName: | ANDREW | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | BCABA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 410286 | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329410286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3214413925 | ||||||||
| FaxNumber: | 8007280287 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 SAINT JOHNS ST | ||||||||
| Address2: | |||||||||
| City: | COCOA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329227241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3216399800 | ||||||||
| FaxNumber: | 3216396007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2010 | ||||||||
| LastUpdateDate: | 04/19/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 0-09-3692 | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.