Provider Demographics
NPI:1558061069
Name:TOLLISON, KAITLIN (LCSW-S)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:
Last Name:TOLLISON
Suffix:
Gender:F
Credentials:LCSW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 LILAC LN
Mailing Address - Street 2:
Mailing Address - City:AZLE
Mailing Address - State:TX
Mailing Address - Zip Code:76020-4410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:216 LILAC LN
Practice Address - Street 2:
Practice Address - City:AZLE
Practice Address - State:TX
Practice Address - Zip Code:76020-4410
Practice Address - Country:US
Practice Address - Phone:972-922-3866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXLCSW-S101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health