Provider Demographics
NPI:1891007860
Name:CUNNINGHAM, LISA (SLP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:SLP
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 65
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32697-0065
Mailing Address - Country:US
Mailing Address - Phone:386-496-3914
Mailing Address - Fax:
Practice Address - Street 1:6398 SOUTH WEST STATE ROAD 121
Practice Address - Street 2:
Practice Address - City:LAKE BUTLER
Practice Address - State:FL
Practice Address - Zip Code:32054
Practice Address - Country:US
Practice Address - Phone:386-496-3914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-07
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA2740235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist