Healthcare Provider Details

I. General information

NPI: 1164785119
Provider Name (Legal Business Name): CHARLES JOHN CUNNING PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2012
Last Update Date: 06/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 WOODSIDE DR
GAFFNEY SC
29340-2853
US

IV. Provider business mailing address

205 WOODSIDE DR
GAFFNEY SC
29340-2853
US

V. Phone/Fax

Practice location:
  • Phone: 864-487-1039
  • Fax:
Mailing address:
  • Phone: 864-487-1039
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: