Provider Demographics
NPI:1003946112
Name:CUNNINGHAM, WAYNE KIERAN (LCMHC, LADC)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:KIERAN
Last Name:CUNNINGHAM
Suffix:
Gender:M
Credentials:LCMHC, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 476
Mailing Address - Street 2:
Mailing Address - City:NORTH CONWAY
Mailing Address - State:NH
Mailing Address - Zip Code:03860-0476
Mailing Address - Country:US
Mailing Address - Phone:603-356-9955
Mailing Address - Fax:
Practice Address - Street 1:2760 MAIN STREET
Practice Address - Street 2:EASTERN SLOPE INN
Practice Address - City:NORTH CONWAY
Practice Address - State:NH
Practice Address - Zip Code:03860
Practice Address - Country:US
Practice Address - Phone:603-356-9955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0331101YA0400X
NH237101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30014439Medicaid