Provider Demographics
NPI:1609909753
Name:TOLLIVER, DWIGHT DAVID
Entity Type:Individual
Prefix:
First Name:DWIGHT
Middle Name:DAVID
Last Name:TOLLIVER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 E BROAD ST STE 301
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-4037
Mailing Address - Country:US
Mailing Address - Phone:614-914-6690
Mailing Address - Fax:147-453-3446
Practice Address - Street 1:620 E BROAD ST STE 301
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-4037
Practice Address - Country:US
Practice Address - Phone:614-914-6690
Practice Address - Fax:614-745-3344
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6578103T00000X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling