Provider Demographics
NPI:1285396515
Name:CUNNINGHAM, BLAKELY RAE (BCBA)
Entity type:Individual
Prefix:
First Name:BLAKELY
Middle Name:RAE
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14864 COUNTY ROAD 433
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75706-3206
Mailing Address - Country:US
Mailing Address - Phone:903-830-2595
Mailing Address - Fax:
Practice Address - Street 1:14864 COUNTY ROAD 433
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75706-3206
Practice Address - Country:US
Practice Address - Phone:903-636-7994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-13
Last Update Date:2024-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106E00000X, 106S00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician