Healthcare Provider Details

I. General information

NPI: 1801870068
Provider Name (Legal Business Name): DARRICK DEWAYNE CUNNINGHAM M.S.W
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/01/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 MDOS/SGOH
APO AP
96266
KR

IV. Provider business mailing address

2667 BLOOMSBERRY RIDGE DR
FUQUAY VARINA NC
27526-7292
US

V. Phone/Fax

Practice location:
  • Phone: 315-784-2149
  • Fax:
Mailing address:
  • Phone: 919-567-2270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number057808
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: