Provider Demographics
NPI:1568528701
Name:CUNNINGHAM, IRENE A (LCSW)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:A
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10900 W BLUEMOUND RD
Mailing Address - Street 2:202
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4156
Mailing Address - Country:US
Mailing Address - Phone:262-352-0357
Mailing Address - Fax:
Practice Address - Street 1:1524 N FARWELL AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-2329
Practice Address - Country:US
Practice Address - Phone:414-273-2220
Practice Address - Fax:414-273-2223
Is Sole Proprietor?:No
Enumeration Date:2006-12-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1976-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39731900Medicaid
WI39731900Medicaid