Provider Demographics
NPI:1063674885
Name:TOLLIVER, KATY L (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KATY
Middle Name:L
Last Name:TOLLIVER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 SOUTH BROAD STREET
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101
Mailing Address - Country:US
Mailing Address - Phone:336-722-8173
Mailing Address - Fax:336-724-6491
Practice Address - Street 1:1200 SOUTH BROAD STREET
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101
Practice Address - Country:US
Practice Address - Phone:336-722-8173
Practice Address - Fax:336-724-6491
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YM0800X, 101YP2500X, 104100000X
NCC0060811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker