Healthcare Provider Details

I. General information

NPI: 1043422397
Provider Name (Legal Business Name): KATHERINE ANNE CUNNINGHAM M.DIV.,
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

589 FRANKLIN TPKE
RIDGEWOOD NJ
07450-1989
US

IV. Provider business mailing address

26 ALPINE DR
NORTH HALEDON NJ
07508-3117
US

V. Phone/Fax

Practice location:
  • Phone: 201-447-9344
  • Fax:
Mailing address:
  • Phone: 973-427-4184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number000459
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: