Provider Demographics
NPI:1114422524
Name:CUNNINGHAM, GRADY EUGENE JR
Entity Type:Individual
Prefix:MR
First Name:GRADY
Middle Name:EUGENE
Last Name:CUNNINGHAM
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 NORTHLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45240-3248
Mailing Address - Country:US
Mailing Address - Phone:513-941-4999
Mailing Address - Fax:513-648-9859
Practice Address - Street 1:680 NORTHLAND BLVD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45240-3248
Practice Address - Country:US
Practice Address - Phone:513-941-4999
Practice Address - Fax:513-648-9859
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-27
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH.165808101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH063000Medicaid
OH287Medicaid