Provider Demographics
NPI:1922722164
Name:FITZSIMMONS-LUCE, PHYLLIS (LCPC, LMHC)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:FITZSIMMONS-LUCE
Suffix:
Gender:F
Credentials:LCPC, LMHC
Other - Prefix:
Other - First Name:PHYLLIS
Other - Middle Name:
Other - Last Name:LUCE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:22 FREE ST STE 402
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-3900
Mailing Address - Country:US
Mailing Address - Phone:207-619-3356
Mailing Address - Fax:
Practice Address - Street 1:22 FREE ST STE 402
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-3900
Practice Address - Country:US
Practice Address - Phone:207-619-3356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-30
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4935101YM0800X
MECC6554101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health