Basic Information
| Provider Information | |||||||||
| NPI: | 1538539572 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TOLLIVER | ||||||||
| FirstName: | HENRY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 931 WESTWOOD DR STE E | ||||||||
| Address2: | |||||||||
| City: | MARRERO | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700722400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5043408880 | ||||||||
| FaxNumber: | 5043408884 | ||||||||
| Practice Location | |||||||||
| Address1: | 931 WESTWOOD DR STE E | ||||||||
| Address2: | |||||||||
| City: | MARRERO | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700722400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5043408880 | ||||||||
| FaxNumber: | 5043408884 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2015 | ||||||||
| LastUpdateDate: | 10/02/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.