Healthcare Provider Details

I. General information

NPI: 1770273088
Provider Name (Legal Business Name): MARISSA CUNNINGHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2023
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11593 LARKSPUR LN
CARMEL IN
46032-8614
US

IV. Provider business mailing address

11593 LARKSPUR LN
CARMEL IN
46032-8614
US

V. Phone/Fax

Practice location:
  • Phone: 317-795-0229
  • Fax:
Mailing address:
  • Phone: 317-795-0229
  • 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: