Provider Demographics
NPI:1386186435
Name:TOLBERT, ROBERT (MA, PLPC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:TOLBERT
Suffix:
Gender:M
Credentials:MA, PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 N THOMAS DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-6503
Mailing Address - Country:US
Mailing Address - Phone:318-424-8345
Mailing Address - Fax:318-424-4417
Practice Address - Street 1:332 LAKE RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:LA
Practice Address - Zip Code:71052-6400
Practice Address - Country:US
Practice Address - Phone:318-872-2085
Practice Address - Fax:318-872-2082
Is Sole Proprietor?:No
Enumeration Date:2016-11-07
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPLC5248101YM0800X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1386186435Medicaid