Provider Demographics
NPI:1417346297
Name:CUNNINGHAM, KENNETH RAY (MFT INTERN)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:RAY
Last Name:CUNNINGHAM
Suffix:
Gender:M
Credentials:MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6280 JACKSON DR STE 7
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92119-3436
Mailing Address - Country:US
Mailing Address - Phone:619-462-2277
Mailing Address - Fax:
Practice Address - Street 1:6280 JACKSON DR STE 7
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92119-3436
Practice Address - Country:US
Practice Address - Phone:619-462-2277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-15
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF73660106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist