Healthcare Provider Details

I. General information

NPI: 1316469802
Provider Name (Legal Business Name): KEN CUNNINGHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2017
Last Update Date: 07/25/2023
Certification Date: 07/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 PACIFICA STE 130
IRVINE CA
92618-7421
US

IV. Provider business mailing address

2733 FAMILY TREE
IRVINE CA
92618-1089
US

V. Phone/Fax

Practice location:
  • Phone: 949-431-6000
  • Fax:
Mailing address:
  • Phone: 847-644-9577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: