Provider Demographics
NPI:1235284100
Name:MARY ALICE CUNNINGHAM PC
Entity Type:Organization
Organization Name:MARY ALICE CUNNINGHAM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY ALICE
Authorized Official - Middle Name:STODDARD
Authorized Official - Last Name:CUNNINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-842-9800
Mailing Address - Street 1:7971 PIONEER ST
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-7418
Mailing Address - Country:US
Mailing Address - Phone:801-842-9800
Mailing Address - Fax:
Practice Address - Street 1:7971 PIONEER ST
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-7418
Practice Address - Country:US
Practice Address - Phone:801-842-9800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT323492-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1093742058OtherLCSW