Provider Demographics
NPI:1912069675
Name:CUNNINGHAM, STACEY R (SLP MSE CCC SLP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:R
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:SLP MSE CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:505 KELLER AVE S
Mailing Address - Street 2:
Mailing Address - City:AMERY
Mailing Address - State:WI
Mailing Address - Zip Code:54001
Mailing Address - Country:US
Mailing Address - Phone:715-268-6900
Mailing Address - Fax:715-268-6895
Practice Address - Street 1:505 KELLER AVE S
Practice Address - Street 2:
Practice Address - City:AMERY
Practice Address - State:WI
Practice Address - Zip Code:54001
Practice Address - Country:US
Practice Address - Phone:715-268-6900
Practice Address - Fax:715-268-6895
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2240154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HP48076OtherHEALTH PARTNERS
WI42793800Medicaid
304K9CUOtherBCBS OF MN
4600981OtherMEDICA INS