Healthcare Provider Details

I. General information

NPI: 1336543719
Provider Name (Legal Business Name): CORRIE CUNNINGHAM LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2014
Last Update Date: 07/20/2021
Certification Date: 07/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 N MAIN AVE STE 201C
GRESHAM OR
97030-7242
US

IV. Provider business mailing address

320 N MAIN AVE STE 201C
GRESHAM OR
97030-7242
US

V. Phone/Fax

Practice location:
  • Phone: 503-770-0213
  • Fax:
Mailing address:
  • Phone: 503-770-0213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCG60490328
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC4427
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: