Provider Demographics
NPI:1730327602
Name:RUNGE, MARK P (SLP)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:P
Last Name:RUNGE
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 HOOVER ST
Mailing Address - Street 2:
Mailing Address - City:NEW HOLSTEIN
Mailing Address - State:WI
Mailing Address - Zip Code:53061-1636
Mailing Address - Country:US
Mailing Address - Phone:920-898-5706
Mailing Address - Fax:
Practice Address - Street 1:1610 HOOVER ST
Practice Address - Street 2:
Practice Address - City:NEW HOLSTEIN
Practice Address - State:WI
Practice Address - Zip Code:53061-1636
Practice Address - Country:US
Practice Address - Phone:920-898-5706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-29
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2047-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist