Healthcare Provider Details

I. General information

NPI: 1144698929
Provider Name (Legal Business Name): EDWARD CUNLIFFE PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2015
Last Update Date: 09/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 LAKE AVE STE 8
LAKE WORTH FL
33460-3846
US

IV. Provider business mailing address

521 LAKE AVE STE 8
LAKE WORTH FL
33460-3846
US

V. Phone/Fax

Practice location:
  • Phone: 305-484-0832
  • Fax: 305-668-7450
Mailing address:
  • Phone: 305-484-0832
  • Fax: 305-668-7450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPY6979
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY6979
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPY6979
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberPY6979
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License NumberPY6979
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License NumberPY6979
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: