Provider Demographics
NPI:1760891121
Name:MCCOLISTER-CUNNINGHAM, PHYLLIS (MS, LMHC, CAP)
Entity Type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:
Last Name:MCCOLISTER-CUNNINGHAM
Suffix:
Gender:F
Credentials:MS, LMHC, CAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 VIRGINIA AVE STE 7
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34982-5882
Mailing Address - Country:US
Mailing Address - Phone:772-448-4189
Mailing Address - Fax:772-245-4259
Practice Address - Street 1:900 VIRGINIA AVE STE 7
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982-5882
Practice Address - Country:US
Practice Address - Phone:772-448-4189
Practice Address - Fax:772-245-4259
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-10
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL650789152101YM0800X
101YM0800X
FLMH14456101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL650789152OtherSUNCOAST