=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801870068
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DARRICK DEWAYNE CUNNINGHAM M.S.W
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 51 MDOS/SGOH
-----------------------------------------------------
City | APO
-----------------------------------------------------
State | AP
-----------------------------------------------------
Zip | 96266
-----------------------------------------------------
Country | KR
-----------------------------------------------------
Telephone | 315-784-2149
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2667 BLOOMSBERRY RIDGE DR
-----------------------------------------------------
City | FUQUAY VARINA
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27526-7292
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-567-2270
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 057808
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------