Provider Demographics
NPI:1033825260
Name:TOLLIVER, COREY ASHTON SR (LMHP-S)
Entity Type:Individual
Prefix:MR
First Name:COREY
Middle Name:ASHTON
Last Name:TOLLIVER
Suffix:SR
Gender:M
Credentials:LMHP-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7000 HOLRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23832-8441
Mailing Address - Country:US
Mailing Address - Phone:804-314-8785
Mailing Address - Fax:
Practice Address - Street 1:7000 HOLRIDGE CT
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23832
Practice Address - Country:US
Practice Address - Phone:804-314-8785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-31
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09060121311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA85-2842697Medicaid