Healthcare Provider Details

I. General information

NPI: 1962551069
Provider Name (Legal Business Name): WILLIAM R CUNNINGHAM JR. MA, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 S MAIN ST SUITE 307
SAINT CHARLES MO
63301-3306
US

IV. Provider business mailing address

12 WINDERMERE CT
SAINT CHARLES MO
63301-4527
US

V. Phone/Fax

Practice location:
  • Phone: 636-947-2325
  • Fax: 636-947-5941
Mailing address:
  • Phone: 636-949-5553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2002032132
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: