Provider Demographics
NPI:1073863767
Name:TOLLEY, BRIANNE J
Entity Type:Individual
Prefix:
First Name:BRIANNE
Middle Name:J
Last Name:TOLLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 E BAGLEY RD
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:OH
Mailing Address - Zip Code:44017-2058
Mailing Address - Country:US
Mailing Address - Phone:800-234-2006
Mailing Address - Fax:
Practice Address - Street 1:5905 BRECKSVILLE RD
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:OH
Practice Address - Zip Code:44131-1517
Practice Address - Country:US
Practice Address - Phone:216-524-4673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-11
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS1000412101YP2500X
OHI.14513321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional