Healthcare Provider Details

I. General information

NPI: 1073908539
Provider Name (Legal Business Name): LAUREN CUNNINGHAM PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2015
Last Update Date: 01/06/2021
Certification Date: 01/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 W ROYALE DR
MUNCIE IN
47304-2265
US

IV. Provider business mailing address

1901 W ROYALE DR
MUNCIE IN
47304-2265
US

V. Phone/Fax

Practice location:
  • Phone: 765-393-1008
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number20043283A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number2063
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number20043283B
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: