Provider Demographics
NPI:1093850703
Name:TOLLEFSON, NATHANIEL MARK
Entity Type:Individual
Prefix:MR
First Name:NATHANIEL
Middle Name:MARK
Last Name:TOLLEFSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1097 N STATE ST
Mailing Address - Street 2:#162
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-1514
Mailing Address - Country:US
Mailing Address - Phone:951-652-7068
Mailing Address - Fax:
Practice Address - Street 1:650 N STATE ST
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-2960
Practice Address - Country:US
Practice Address - Phone:951-791-3350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)