Provider Demographics
NPI:1831310697
Name:CUNNINGHAM, KENNETH JAMES (PHD, LISW, LMSW)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JAMES
Last Name:CUNNINGHAM
Suffix:
Gender:M
Credentials:PHD, LISW, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11351 W. FERNDALE DR., MANITOU BEACH, MICHIGAN 49253
Mailing Address - Street 2:2805 COLLINGWOOD BLVD., TOLEDO, OHIO, 43610
Mailing Address - City:MANITOU BEACH
Mailing Address - State:MI
Mailing Address - Zip Code:49253
Mailing Address - Country:US
Mailing Address - Phone:419-245-0409
Mailing Address - Fax:517-265-4406
Practice Address - Street 1:310 E. MAUMEE ST., ADRIAN, MICHIGAN 49221
Practice Address - Street 2:2805 COLLINGWOOD BLVD., TOLEDO, OHIO 43610
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221
Practice Address - Country:US
Practice Address - Phone:419-245-0409
Practice Address - Fax:517-265-4406
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010341791041C0700X
OH00101401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0891442Medicare ID - Type Unspecified