Provider Demographics
NPI:1104637669
Name:CUNNINGHAM-GLOSTER, ALEXIS ANN
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:ANN
Last Name:CUNNINGHAM-GLOSTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5779 GRAPE RD
Mailing Address - Street 2:PMB 171
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4609 GRAPE RD STE D1B
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-8259
Practice Address - Country:US
Practice Address - Phone:574-217-1624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-15
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-23-255438106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician