MEDICARE: BRANDY CUNNINGHAM

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	106S00000X	Behavior Technician		VA
2	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1770286106
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDY CUNNINGHAM

Provider Business Mailing Address
First Line	:	4102 MIDDLE RIDGE DR
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22033-3226
Country	:	US
Telephone Number	:	312-450-9374
Fax Number	:

Provider Business Practice Location Address
First Line	:	4102 MIDDLE RIDGE DR
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22033-3226
Country	:	US
Telephone Number	:	312-450-9374
Fax Number	:

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

Provider Enumeration Date	:	03/24/2023
Last Update Date	:	05/05/2023

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Directions to “ BRANDY CUNNINGHAM ” Practice Location

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