Provider Demographics
NPI:1609913284
Name:CUNNINGHAM, STACI (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:388 HIGH TIDE DR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-2309
Mailing Address - Country:US
Mailing Address - Phone:904-599-8092
Mailing Address - Fax:
Practice Address - Street 1:388 HIGH TIDE DR
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-2309
Practice Address - Country:US
Practice Address - Phone:904-599-8092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2013-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA8608235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL891528800Medicaid