Provider Demographics
NPI:1114426848
Name:CUNNINGHAM, KELSEY (EIS, LBSW)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:EIS, LBSW
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:EIS, LBSW
Mailing Address - Street 1:9996 COUNTY LINE RD N
Mailing Address - Street 2:
Mailing Address - City:ELECTRA
Mailing Address - State:TX
Mailing Address - Zip Code:76360-3606
Mailing Address - Country:US
Mailing Address - Phone:806-731-2290
Mailing Address - Fax:
Practice Address - Street 1:1709 10TH ST
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-5010
Practice Address - Country:US
Practice Address - Phone:940-696-6200
Practice Address - Fax:940-696-6210
Is Sole Proprietor?:No
Enumeration Date:2018-02-08
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX59451104100000X
TX15-0037174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker