Provider Demographics
NPI:1548273485
Name:CUNNINGHAM, KIMBERLY LAQUERRE (MSPT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LAQUERRE
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ANN
Other - Last Name:LAQUERRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSPT
Mailing Address - Street 1:7 ELM ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-3669
Mailing Address - Country:US
Mailing Address - Phone:860-741-2242
Mailing Address - Fax:860-741-2248
Practice Address - Street 1:7 ELM ST
Practice Address - Street 2:SUITE 204
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-3669
Practice Address - Country:US
Practice Address - Phone:860-741-2242
Practice Address - Fax:860-741-2248
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT007675225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004251211Medicaid
CT076572Medicare ID - Type UnspecifiedGROUP ID