1235273962 NPI number — MS. KIMBERLE MARY CUNNINGHAM LPC LMFT LAC

Table of content: MS. KIMBERLE MARY CUNNINGHAM LPC LMFT LAC (NPI 1235273962)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235273962 NPI number — MS. KIMBERLE MARY CUNNINGHAM LPC LMFT LAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CUNNINGHAM
Provider First Name:
KIMBERLE
Provider Middle Name:
MARY
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LPC LMFT LAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235273962
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/01/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
908 ERIE STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHREVEPORT
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71106
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-840-9399
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
641 OLIVE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71104-2209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-841-5657
Provider Business Practice Location Address Fax Number:
318-584-7140
Provider Enumeration Date:
02/16/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  1119 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106H00000X , with the licence number: 676 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 2501 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)