Provider Demographics
NPI:1609118611
Name:CUNNINGHAM, DEREK J (OT/R)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:J
Last Name:CUNNINGHAM
Suffix:
Gender:M
Credentials:OT/R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 BIRCH RD
Mailing Address - Street 2:
Mailing Address - City:MAHWAH
Mailing Address - State:NJ
Mailing Address - Zip Code:07430-3006
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 CHARLOTTE PL
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD CLIFFS
Practice Address - State:NJ
Practice Address - Zip Code:07632-2615
Practice Address - Country:US
Practice Address - Phone:201-446-6440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-18
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00608400174400000X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No174400000XOther Service ProvidersSpecialist