Healthcare Provider Details

I. General information

NPI: 1548004567
Provider Name (Legal Business Name): SARA CUNNINGHAM PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2024
Last Update Date: 06/24/2024
Certification Date: 06/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 CORNELL RD STE 2
LATHAM NY
12110-1490
US

IV. Provider business mailing address

950 DANBY RD STE 202F
ITHACA NY
14850-5714
US

V. Phone/Fax

Practice location:
  • Phone: 518-510-3100
  • Fax:
Mailing address:
  • Phone: 607-260-3100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number026342
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: