Provider Demographics
NPI:1497137145
Name:CUNNINGHAM, LAQUITTA
Entity Type:Individual
Prefix:
First Name:LAQUITTA
Middle Name:
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1464 HUMPHREY DR APT A
Mailing Address - Street 2:
Mailing Address - City:SUISUN CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94585-1920
Mailing Address - Country:US
Mailing Address - Phone:415-359-5201
Mailing Address - Fax:
Practice Address - Street 1:1515 MARKET AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94806-4357
Practice Address - Country:US
Practice Address - Phone:415-359-5201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-18
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1265560130Medicaid