Provider Demographics
NPI:1568956217
Name:TOLER, MELLISSA MENOLY
Entity Type:Individual
Prefix:
First Name:MELLISSA
Middle Name:MENOLY
Last Name:TOLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELLISSA
Other - Middle Name:MENOLY
Other - Last Name:MILAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9000 POPPY DR APT 9104
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75218-4609
Mailing Address - Country:US
Mailing Address - Phone:214-601-8323
Mailing Address - Fax:
Practice Address - Street 1:400 E ROYAL LN STE 290
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75039-3602
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-17
Last Update Date:2018-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician