Provider Demographics
NPI:1215410741
Name:CUNNINGHAM, CLINTON KEITH
Entity Type:Individual
Prefix:
First Name:CLINTON
Middle Name:KEITH
Last Name:CUNNINGHAM
Suffix:
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 1:405 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:PELLA
Mailing Address - State:IA
Mailing Address - Zip Code:50219-1290
Mailing Address - Country:US
Mailing Address - Phone:641-621-2200
Mailing Address - Fax:641-621-2335
Practice Address - Street 1:405 MONROE ST
Practice Address - Street 2:
Practice Address - City:PELLA
Practice Address - State:IA
Practice Address - Zip Code:50219-1290
Practice Address - Country:US
Practice Address - Phone:641-621-2200
Practice Address - Fax:641-621-2335
Is Sole Proprietor?:No
Enumeration Date:2018-09-11
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA087027106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1215410741OtherNPI #
IA087027OtherIOWA LICENSE
IA007829OtherIOWA LICENSE