=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124268206
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN CUNNINGHAM LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2009
-----------------------------------------------------
Last Update Date | 03/02/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3101 FONTAINE AVENUE EXTENDED
-----------------------------------------------------
City | CHARLOTTESVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22903-9618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-989-4620
-----------------------------------------------------
Fax | 434-979-0802
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3101 FONTAINE AVENUE EXTENDED
-----------------------------------------------------
City | CHARLOTTESVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22903-9618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-989-4620
-----------------------------------------------------
Fax | 434-979-0802
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 0701003109
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------