Provider Demographics
NPI:1326100272
Name:TOLLIVER, DEBRA Y (PT)
Entity Type:Individual
Prefix:MRS
First Name:DEBRA
Middle Name:Y
Last Name:TOLLIVER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1349 S FARM ROAD 199
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65809-3346
Mailing Address - Country:US
Mailing Address - Phone:417-830-4040
Mailing Address - Fax:
Practice Address - Street 1:1349 S FARM ROAD 199
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65809-3346
Practice Address - Country:US
Practice Address - Phone:417-887-0222
Practice Address - Fax:417-887-1916
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO00776174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO431603300Medicare UPIN