Provider Demographics
NPI:1023359171
Name:CUNNINGHAM, LILLIE KORAN (LMFT)
Entity Type:Individual
Prefix:
First Name:LILLIE
Middle Name:KORAN
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 ANDERSON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT VALLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31030-4140
Mailing Address - Country:US
Mailing Address - Phone:478-477-3383
Mailing Address - Fax:
Practice Address - Street 1:6601 ZEBULON RD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31220-7606
Practice Address - Country:US
Practice Address - Phone:478-477-3383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-13
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMFT001354106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist