Provider Demographics
NPI:1023589082
Name:RUNDQUIST, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:RUNDQUIST
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 1:2823 WAYZATA BLVD
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55405-2125
Mailing Address - Country:US
Mailing Address - Phone:612-374-0506
Mailing Address - Fax:651-323-2051
Practice Address - Street 1:7250 METRO BLVD STE 100
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55439-2145
Practice Address - Country:US
Practice Address - Phone:612-374-0506
Practice Address - Fax:651-323-2051
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN300347101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)