MEDICARE: MRS. CAROL JEAN CUNNINGHAM LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	1801	MN

General Provider Information

NPI Number	:	1023178225
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CAROL JEAN CUNNINGHAM LICSW

Provider Business Mailing Address
First Line	:	2116 CAMPUS DRIVE SE
Second Line	:
City	:	ROCHESTER
State	:	MN
Zip	:	55904
Country	:	US
Telephone Number	:	507-285-8488
Fax Number	:	507-287-2371

Provider Business Practice Location Address
First Line	:	2116 CAMPUS DRIVE SE
Second Line	:
City	:	ROCHESTER
State	:	MN
Zip	:	55904
Country	:	US
Telephone Number	:	507-285-8488
Fax Number	:	507-287-2371

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/11/2006
Last Update Date	:	07/08/2007

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