Healthcare Provider Details

I. General information

NPI: 1275974578
Provider Name (Legal Business Name): ELIZABETH ANN CUNNINGHAM PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ELIZABETH ANN MOORE MA, LPC

II. Dates (important events)

Enumeration Date: 07/15/2013
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

144 N COURT ST
DIXON IL
61021-1224
US

IV. Provider business mailing address

1442 STONEBRIDGE CIR APT I8
WHEATON IL
60189-7188
US

V. Phone/Fax

Practice location:
  • Phone: 815-288-1905
  • Fax:
Mailing address:
  • Phone: 419-233-3149
  • 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: