Healthcare Provider Details

I. General information

NPI: 1235284100
Provider Name (Legal Business Name): MARY ALICE CUNNINGHAM PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7971 PIONEER ST
MIDVALE UT
84047-7418
US

IV. Provider business mailing address

7971 PIONEER ST
MIDVALE UT
84047-7418
US

V. Phone/Fax

Practice location:
  • Phone: 801-842-9800
  • Fax:
Mailing address:
  • Phone: 801-842-9800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number323492-3501
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1093742058
Identifier TypeOTHER
Identifier StateUT
Identifier IssuerLCSW

VIII. Authorized Official

Name: MS. MARY ALICE STODDARD CUNNINGHAM
Title or Position: CEO
Credential: LCSW
Phone: 801-842-9800