Provider Demographics
NPI:1194889154
Name:CUNNINGHAM, MJ (MSW, LISW)
Entity type:Individual
Prefix:
First Name:MJ
Middle Name:
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:MSW, LISW
Other - Prefix:
Other - First Name:MARY JEAN
Other - Middle Name:
Other - Last Name:CUNNINGHAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW, LISW
Mailing Address - Street 1:1522 HERMOSA DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-5625
Mailing Address - Country:US
Mailing Address - Phone:505-440-2682
Mailing Address - Fax:
Practice Address - Street 1:1522 HERMOSA DR NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-5625
Practice Address - Country:US
Practice Address - Phone:505-440-2682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-3585104100000X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Not Answered1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool