Provider Demographics
NPI:1417475666
Name:CUNNINGHAM, CAITLIN CARLSON (DPT)
Entity Type:Individual
Prefix:
First Name:CAITLIN
Middle Name:CARLSON
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:373 BLAIR PARK RD UNIT 204
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-8056
Mailing Address - Country:US
Mailing Address - Phone:802-662-4672
Mailing Address - Fax:802-662-5964
Practice Address - Street 1:373 BLAIR PARK RD UNIT 204
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-8056
Practice Address - Country:US
Practice Address - Phone:802-662-4672
Practice Address - Fax:802-662-5964
Is Sole Proprietor?:No
Enumeration Date:2017-09-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0400130263225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1019108Medicaid