Provider Demographics
NPI:1740571363
Name:CUNNINGHAM, BRENT R (CADC, LSAC)
Entity Type:Individual
Prefix:MR
First Name:BRENT
Middle Name:R
Last Name:CUNNINGHAM
Suffix:
Gender:M
Credentials:CADC, LSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 242
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83303-0242
Mailing Address - Country:US
Mailing Address - Phone:208-420-9952
Mailing Address - Fax:208-423-7029
Practice Address - Street 1:284 MARTIN ST
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-4542
Practice Address - Country:US
Practice Address - Phone:208-420-9952
Practice Address - Fax:208-423-7029
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-30
Last Update Date:2011-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7726920-6006101YA0400X
ID1021897 CADC101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)