Provider Demographics
NPI:1174125165
Name:CUNNINGHAM, MARK R (MFT-C)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:CUNNINGHAM
Suffix:
Gender:M
Credentials:MFT-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1531 W SWALLOW RD APT 36
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-2397
Mailing Address - Country:US
Mailing Address - Phone:702-885-6473
Mailing Address - Fax:
Practice Address - Street 1:2625 REDWING RD UNIT 175 OFFICE 1
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526
Practice Address - Country:US
Practice Address - Phone:970-825-3848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-13
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMFTC.0013774106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist