Provider Demographics
NPI:1023096856
Name:CUNNINGHAM, CHANNON M (MSW, LCSW, CAC/CCDP)
Entity type:Individual
Prefix:MRS
First Name:CHANNON
Middle Name:M
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:MSW, LCSW, CAC/CCDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 MARKET ST
Mailing Address - Street 2:STE 114
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-6321
Mailing Address - Country:US
Mailing Address - Phone:570-212-9481
Mailing Address - Fax:570-651-9250
Practice Address - Street 1:460 MARKET ST
Practice Address - Street 2:STE 114
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-6321
Practice Address - Country:US
Practice Address - Phone:570-212-9481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
PACW0148601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1362328OtherBLUE CROSS/BLUE SHIELD
PAQ32730Medicare UPIN
PA087055PX0Medicare PIN