Provider Demographics
NPI:1609565795
Name:TOLLIVER, LORETTA B (EDD)
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:B
Last Name:TOLLIVER
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3561 BOXWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-4229
Mailing Address - Country:US
Mailing Address - Phone:618-578-1413
Mailing Address - Fax:
Practice Address - Street 1:3561 BOXWOOD DR
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-4229
Practice Address - Country:US
Practice Address - Phone:618-578-1413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-04
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL172V00000X
CA171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach
No172V00000XOther Service ProvidersCommunity Health Worker