Provider Demographics
NPI:1720631609
Name:CUNNINGHAM, GRANT WILLIAM
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:WILLIAM
Last Name:CUNNINGHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22550 SW HIGHLAND DR APT 340
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:OR
Mailing Address - Zip Code:97140-7041
Mailing Address - Country:US
Mailing Address - Phone:720-988-9565
Mailing Address - Fax:
Practice Address - Street 1:880 82ND DR
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:OR
Practice Address - Zip Code:97027-1803
Practice Address - Country:US
Practice Address - Phone:503-659-5515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-19
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19-R-14101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)