MEDICARE: SUE ELLEN CUNNINGHAM PCCS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	E4142	OH

General Provider Information

NPI Number	:	1720315708
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUE ELLEN CUNNINGHAM PCCS

Provider Business Mailing Address
First Line	:	76 ASHWOOD DR
Second Line	:
City	:	TIFFIN
State	:	OH
Zip	:	44883-1908
Country	:	US
Telephone Number	:	419-448-9440
Fax Number	:	419-448-5155

Provider Business Practice Location Address
First Line	:	76 ASHWOOD DR
Second Line	:
City	:	TIFFIN
State	:	OH
Zip	:	44883-1908
Country	:	US
Telephone Number	:	419-448-9440
Fax Number	:	419-448-5155

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/11/2009
Last Update Date	:	11/11/2009

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