Provider Demographics
NPI:1356757900
Name:CUNNINGHAM, DESERI ALICIA (PSYD, LP)
Entity type:Individual
Prefix:
First Name:DESERI
Middle Name:ALICIA
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:DESERI
Other - Middle Name:ALICIA
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1300 E BRADFORD PKWY
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-4264
Mailing Address - Country:US
Mailing Address - Phone:417-761-5000
Mailing Address - Fax:417-761-5011
Practice Address - Street 1:230 N BELCREST AVE STE A
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802-6287
Practice Address - Country:US
Practice Address - Phone:417-413-4676
Practice Address - Fax:417-763-3308
Is Sole Proprietor?:No
Enumeration Date:2014-07-03
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014022296101YM0800X
MO2016035950103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490014993Medicaid