Provider Demographics
NPI:1669727392
Name:RUNGE, EDGAR GUSTAVE JR (MA, LPC, CCS)
Entity type:Individual
Prefix:MR
First Name:EDGAR
Middle Name:GUSTAVE
Last Name:RUNGE
Suffix:JR
Gender:M
Credentials:MA, LPC, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1470 BEN SAWYER BLVD
Mailing Address - Street 2:SUITE 5B
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464
Mailing Address - Country:US
Mailing Address - Phone:843-276-2492
Mailing Address - Fax:
Practice Address - Street 1:1470 BEN SAWYER BLVD
Practice Address - Street 2:SUITE 5B
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-4591
Practice Address - Country:US
Practice Address - Phone:843-276-2492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-18
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC101YA0400X
SC3496101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)