Provider Demographics
NPI:1194929042
Name:CUNNINGHAM-BRYANT, MARY (PHD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:CUNNINGHAM-BRYANT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 TAMAL VISTA BLVD STE 150
Mailing Address - Street 2:
Mailing Address - City:CORTE MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:94925-1156
Mailing Address - Country:US
Mailing Address - Phone:415-927-7748
Mailing Address - Fax:415-927-1646
Practice Address - Street 1:240 TAMAL VISTA BLVD STE 162
Practice Address - Street 2:
Practice Address - City:CORTE MADERA
Practice Address - State:CA
Practice Address - Zip Code:94925-1156
Practice Address - Country:US
Practice Address - Phone:415-927-7748
Practice Address - Fax:415-927-1646
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10067103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist