Basic Information
| Provider Information | |||||||||
| NPI: | 1386186435 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TOLBERT | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.A., PLPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 N THOMAS DR | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711076503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184248345 | ||||||||
| FaxNumber: | 3184244417 | ||||||||
| Practice Location | |||||||||
| Address1: | 332 LAKE RD | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | LA | ||||||||
| PostalCode: | 710526400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3188722085 | ||||||||
| FaxNumber: | 3188722082 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2016 | ||||||||
| LastUpdateDate: | 01/28/2019 | ||||||||
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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 | 101YM0800X | PLC5248 | LA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 1386186435 | 05 | LA | MEDICAID |