Provider Demographics
NPI:1306047048
Name:CUNNINGHAM PETROS, JULIA (PSYD)
Entity type:Individual
Prefix:DR
First Name:JULIA
Middle Name:
Last Name:CUNNINGHAM PETROS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:JULIA
Other - Middle Name:
Other - Last Name:CUNNINGHAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:3940 PENINSULAR DR SE STE 230
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-6187
Mailing Address - Country:US
Mailing Address - Phone:616-458-0692
Mailing Address - Fax:616-458-8129
Practice Address - Street 1:3940 PENINSULAR DR SE STE 230
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6187
Practice Address - Country:US
Practice Address - Phone:616-458-0692
Practice Address - Fax:616-458-8129
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013937103TC0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1003859984OtherGROUP NPI