Basic Information
| Provider Information | |||||||||
| NPI: | 1922252352 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CUNNINGHAM | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 141 E MAIN ST | ||||||||
| Address2: | 4TH FLOOR ADMINISTRATION | ||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067022310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035749000 | ||||||||
| FaxNumber: | 2035749006 | ||||||||
| Practice Location | |||||||||
| Address1: | 141 E MAIN ST | ||||||||
| Address2: | WATERBURY CLINICAL SERVICES | ||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067022310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037567287 | ||||||||
| FaxNumber: | 2032360122 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2008 | ||||||||
| LastUpdateDate: | 07/26/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 000073 | CT | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 060669107 | 01 | CT | UBH/CONNECTICARE WELLMORE GRP/FACILITY | OTHER | 060669107 | 01 | CT | UBH/OPTUM BEHAVIORAL HEALTH WELLMORE GRP/FACILITY | OTHER | 008037428 | 05 | CT | MEDICAID | 060669107 | 01 | CT | ANTHEM BCBS OF CT WELLMORE GRP/FACILITY | OTHER | 4853958 | 01 | CT | CIGNA BEHAVIORAL HEALTH | OTHER | 9790693 | 01 | CT | AETNA BEHAVIORAL HEALTH | OTHER | 060669107 | 01 | CT | UBH/LIBERTY FREEDOM WELLMORE GRP/FACILITY | OTHER | 390290 | 01 | CT | MHN-TRICARENORTH | OTHER | 11241824 | 01 | CT | CAQH | OTHER | 390290 | 01 | CT | MHN- MANAGED HEALTH NETWORK | OTHER | D339123 WATERBURY | 01 | CT | BEACON HEALTH STRATEGIES WELLMORE GRP/FACILITY | OTHER | 060669107 | 01 | CT | HEALTHYCT WELLMORE GRP/FACILITY | OTHER | 060669107 | 01 | CT | UBH/UNITED HEALTHCARE WELLMORE GRP/FACILITY | OTHER |