=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558319442
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARAYEH CUNNINGHAM PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2006
-----------------------------------------------------
Last Update Date | 02/03/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 26 TUBAC ROAD SUITE B
-----------------------------------------------------
City | TUBAC
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85646-1990
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-398-3970
-----------------------------------------------------
Fax | 520-398-2944
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1990
-----------------------------------------------------
City | TUBAC
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85646-1990
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-398-3970
-----------------------------------------------------
Fax | 520-398-2944
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 3784
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------