=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154951242
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBIN LYNN CUNNINGHAM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2020
-----------------------------------------------------
Last Update Date | 03/25/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1116 ALICE ST
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95350-5905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-578-3132
-----------------------------------------------------
Fax | 209-578-3498
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 127 E EATON AVE
-----------------------------------------------------
City | TRACY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95376-3123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-597-0199
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------