Provider Demographics
NPI:1043587926
Name:CUNNINGHAM, KIM MARIE
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:MARIE
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:
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 34703
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1703
Mailing Address - Country:US
Mailing Address - Phone:206-764-3335
Mailing Address - Fax:206-764-0489
Practice Address - Street 1:5007 CLAREMONT WAY
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203-3321
Practice Address - Country:US
Practice Address - Phone:425-347-5415
Practice Address - Fax:425-347-2976
Is Sole Proprietor?:No
Enumeration Date:2011-11-21
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60158789101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)