Provider Demographics
NPI:1114379914
Name:CUNNINGHAM, KELLY LOUISE
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LOUISE
Last Name:CUNNINGHAM
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 1:626 CENTRAL AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02861-1958
Mailing Address - Country:US
Mailing Address - Phone:603-381-1914
Mailing Address - Fax:
Practice Address - Street 1:626 CENTRAL AVE APT 3
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02861-1958
Practice Address - Country:US
Practice Address - Phone:603-381-1914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-06
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA410400101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health