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General NPI Number Information
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NPI Number | 1740571363
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Entity Type | Individual
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Provider Name | BRENT R CUNNINGHAM CADC, LSAC
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Gender | Male
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Dates
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Enumeration Date | 04/30/2011
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Last Update Date | 04/30/2011
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Provider Practice Location Address
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Address Line | 284 MARTIN ST
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City | TWIN FALLS
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State | ID
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Zip | 83301-4542
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Country | US
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Telephone | 208-420-9952
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Fax | 208-423-7029
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Provider Business Mailing Address
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Address Line | PO BOX 242
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City | TWIN FALLS
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State | ID
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Zip | 83303-0242
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Country | US
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Telephone | 208-420-9952
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Fax | 208-423-7029
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 7726920-6006
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License Number State | UT
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 1021897 CADC
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License Number State | ID
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