Provider Demographics
NPI:1013116607
Name:CUNNINGHAM, STACEY L (LPC)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:L
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 ALLEY A
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:TX
Mailing Address - Zip Code:78602-3240
Mailing Address - Country:US
Mailing Address - Phone:512-581-8435
Mailing Address - Fax:512-332-2025
Practice Address - Street 1:1011 ALLEY A ST
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:TX
Practice Address - Zip Code:78602-3240
Practice Address - Country:US
Practice Address - Phone:512-581-8435
Practice Address - Fax:512-332-2025
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19686101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional