Healthcare Provider Details

I. General information

NPI: 1114422524
Provider Name (Legal Business Name): MR. GRADY EUGENE CUNNINGHAM JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2018
Last Update Date: 03/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 NORTHLAND BLVD
CINCINNATI OH
45240-3248
US

IV. Provider business mailing address

680 NORTHLAND BLVD
CINCINNATI OH
45240-3248
US

V. Phone/Fax

Practice location:
  • Phone: 513-941-4999
  • Fax: 513-648-9859
Mailing address:
  • Phone: 513-941-4999
  • Fax: 513-648-9859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number.165808
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: