Provider Demographics
NPI:1942742952
Name:CUNNINGHAM, BRIAN (CASAC-T)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:CUNNINGHAM
Suffix:
Gender:M
Credentials:CASAC-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 CHURCH AVE
Mailing Address - Street 2:
Mailing Address - City:ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11751-3902
Mailing Address - Country:US
Mailing Address - Phone:631-449-0892
Mailing Address - Fax:
Practice Address - Street 1:1444 5TH AVE
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-4147
Practice Address - Country:US
Practice Address - Phone:631-647-3113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-08
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY31718103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)