Healthcare Provider Details

I. General information

NPI: 1588320295
Provider Name (Legal Business Name): BRANDON MARK CUNNINGHAM LCSW, LSCSW, CRADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2021
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1707 E CEDAR ST STE 103
OLATHE KS
66062-1886
US

IV. Provider business mailing address

PO BOX 19114
LENEXA KS
66285-9114
US

V. Phone/Fax

Practice location:
  • Phone: 620-262-7771
  • Fax:
Mailing address:
  • Phone: 913-523-6081
  • Fax: 913-392-7199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number11808
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2021036486
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number05584
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: