Provider Demographics
NPI:1053140483
Name:RUNYAN, BRYAN
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:RUNYAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4953 BUENA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:DUMFRIES
Mailing Address - State:VA
Mailing Address - Zip Code:22025-3053
Mailing Address - Country:US
Mailing Address - Phone:318-623-8468
Mailing Address - Fax:
Practice Address - Street 1:107 CARPENTER DR STE 110
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20164-4468
Practice Address - Country:US
Practice Address - Phone:703-297-4368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-01
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist