Provider Demographics
NPI:1336348275
Name:COLE, PHYLLIS LEIGH (PSYD, LPC)
Entity Type:Individual
Prefix:DR
First Name:PHYLLIS
Middle Name:LEIGH
Last Name:COLE
Suffix:
Gender:F
Credentials:PSYD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020 S SAGAMONT AVE APT E12
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-4930
Mailing Address - Country:US
Mailing Address - Phone:417-894-5262
Mailing Address - Fax:
Practice Address - Street 1:3020 S SAGAMONT AVE APT E12
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-4930
Practice Address - Country:US
Practice Address - Phone:417-894-5262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-12
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002009573101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO495755803Medicaid