Provider Demographics
NPI:1194856864
Name:CUNNINGHAM, CHARLA KAY (LMFT RDT)
Entity Type:Individual
Prefix:MS
First Name:CHARLA
Middle Name:KAY
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:LMFT RDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1925 GLENMORRIE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-6341
Mailing Address - Country:US
Mailing Address - Phone:503-635-3401
Mailing Address - Fax:
Practice Address - Street 1:7824 SE 13TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202
Practice Address - Country:US
Practice Address - Phone:503-735-5870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT0524103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR0000WCKDKMedicare ID - Type Unspecified