Provider Demographics
NPI:1558827899
Name:TOLLIVER, DEMETRICE E
Entity Type:Individual
Prefix:
First Name:DEMETRICE
Middle Name:E
Last Name:TOLLIVER
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 1:8070A CROWDER BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70127-1063
Mailing Address - Country:US
Mailing Address - Phone:504-410-2316
Mailing Address - Fax:
Practice Address - Street 1:8070A CROWDER BLVD
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70127-1063
Practice Address - Country:US
Practice Address - Phone:504-410-2316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-12
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA000000000Medicaid