Provider Demographics
NPI:1114302775
Name:CUNNINGHAM, SUSAN MAE (MA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MAE
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8131 GRISSOM CIR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78251-2831
Mailing Address - Country:US
Mailing Address - Phone:702-824-5561
Mailing Address - Fax:
Practice Address - Street 1:4230 GARDENDALE ST STE 601
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3482
Practice Address - Country:US
Practice Address - Phone:210-879-8632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-24
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX75812101YP2500X
TX202588106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional